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DISEASES 



NOSE, THROAT AND EAR 



MEDICAL AND SURGICAL 



BY 

WILLIAM LINCOLN BALLENGEE, M.D. 

W 

PROFESSOR OF OTOLOGY, RHINOLOGY, AND LARYNGOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS 

DEPARTMENT OF MEDICINE, UNIVERSITY OF ILLINOIS, CHICAGO; FELLOW OF THE AMERICAN 

LARYNGOLOGICAL ASSOCIATION; FELLOW OF THE AMERICAN LARYNGOLOGICAL, 

RHINOLOGICAL, AND OTOLOGICAL ASSOCIATION; FELLOW OF THE AMERICAN 

ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY, ETC. 



FOURTH EDITION, REVISED AND ENLARGED 



ILLUSTRATED WITH 536 ENGRAVINGS AND 33 PLATES 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1914. 



^ 






Entered according to Act of Congress, in the year 1914, by 

LEA & FEBIGER 
in the Office of the Librarian of Congress. All rights reserved. 



JUL 2^ 19(4 • 

©CI.A37674S 



PREFACE TO THE FOURTH EDITION 



The distinguishing feature of this new edition will be found in its 
chapters on the Labyrinth. Great labor has been bestowed in marshal- 
ling the facts and formulating them for teaching purposes. Thirteen 
original colored plates now illustrate the physiological and pathological 
manifestations of nystagmus. A careful study of these alone will 
suffice to convey a clear idea of the subject. The new matter on the 
Labyrinth amounts to over one hundred pages. The author is indebted 
to Dr. J. R. Fletcher for the section on General Diagnosis of Labyrinth 
Disease, which he has revised. Twelve drawings illustrate the Neumann 
and the Hinsberg labyrinth operations. 

The call for a new edition has been utilized to subject the entire 
book to a searching revision and to bring it fully to date. Among 
other new matters may be mentioned the full description of Mosher's 
fronto-ethmoid operation, with five drawings, showing each step. 
Mosher's technique is a distinct advance in the surgery of the 
sinuses. Autogenous vaccines in the treatment of hay fever, as advo- 
cated by Dr. T. M. Farrington, are given place, though this remedy 
has not yet fully proved its value. Space is given to it with the hope 
that others will subject it to a thorough trial, as it offers a fruitful field 
for research. Dr. Alfred Lewy has rewritten the section on Functional 
Tests of Hearing. Otosclerosis has been extensively revised and brought 
fully to date. Haynes' operation on the cisterna magna is fully de- 
scribed, and five drawings illustrate the technique. Vaccine therapy 
has been revised, and the His leukocyte-extract therapy is given in 
detail. It forms a distinct advance in the treatment of certain forms 
of infectious diseases, especially of the nasal sinuses and meninges. 
Meningitis has been largely rewritten, with much new material. The 
section on Abscess of the Brain has been revised by Dr. Howard Charles 
Ballenger. The use of salvarsan in the treatment of syphilis of the 
brain and auditory nerve is described with great fulness. It forms an 
important addition to this edition. Dr. George McBeam's theory of 
the causation of paracusis Willisii is given in full. In a word, every 

(v) 



Vl PREFACE TO THE FOURTH EDITION 

line of the book has been revised, all obsolete matter has been 
eliminated, and much new text has been incorporated, with many 
new illustrations and plates, all of which were drawn by the author. 
He believes that the work, thus brought to date, affords a well-balanced 
presentation of its closely related specialties, and that it covers the 
field. He hopes, therefore, that it will continue to enjoy the favor 
which has called for four large editions in six years. 

The author takes this opportunity of thanking Dr. C. E. Robb, 
who has read the proof, and Dr. Howard Charles Ballenger, his pro- 
fessional associate, who has also rendered valuable assistance in the 
proof-reading and in the revision of the section on Intracranial 
Complications in Aural Disease. Dr. Robb has also carefully revised 
the entire text for the avoidance of errors. 

W. L. B. 

Chicago, 1914. 



CONTENTS 



PART I 

THE NOSE AND ACCESSORY SINUSES 

CHAPTER I 

THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND 

ACCESSORY SINUSES 17 

CHAPTER II 

THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL 

MEDICINE 26 

CHAPTER III 
THE OFFICE EQUIPMENT . . . . . . 36 

CHAPTER IV 

THE ETIOLOGY OF DEFORMITIES AND DEVIATIONS OF THE 

SEPTUM NASI 57 

CHAPTER V 

THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL 
CORRECTION OF OBSTRUCTIVE MALFORMATIONS OF THE 
SEPTUM 67 

CHAPTER VI 

THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE 

AND ACCESSORY SINUSES 110 

CHAPTER VII 

THE METHODS FOR PROMOTING THE REACTION OF INFLAM- 
MATION ... 122 

CHAPTER VIII 
INFLAMMATORY DISEASES OF THE NOSE . . . . . . . 130 

CHAPTER IX 

THE INDIVIDUAL SINUSES „ . . , . . . 161 

(vii) 



Viii CONTENTS 

CHAPTER X 
GENERAL CONSIDERATIONS IN REFERENCE TO THE SINUSES 176 

CHAPTER XI 
THE SURGERY OF THE ACCESSORY SINUSES ....... 199 

CHAPTER XII 

NASAL NEUROSES. NASAL HYDRORRHEA. CEREBROSPINAL 

RHINORRHEA ...... . . . ...... 253 

CHAPTER XIII 
NEOPLASMS OF THE NOSE .......... . „ . 269 

CHAPTER XIV 

EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. FURUN- 

CULOSIS. SCREW-WORMS ........... 284 

CHAPTER XV 
SURGICAL CORRECTION OF EXTERNAL NASAL DEFORMITIES . 291 

CHAPTER XVI 
CHRONIC GRANULOMATA OF THE NOSE, THROAT, AND EAR . 304 



PAET II 

THE PHARYNX AND FAUCES 

CHAPTER XVII 
DISEASES OF THE EPIPHARYNX AND BASE OF THE TONGUE 331 

CHAPTER XVIII 
INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES 352 

CHAPTER XIX 
FUNCTIONAL NEUROSES OF THE PHARYNX . „ . . . . . 364 

CHAPTER XX 
NEOPLASMS OF THE PHARYNX ........... 368 



CONTENTS i x 

CHAPTER XXI 
DISEASES OF THE FAUCES AND TONSILS . . . . „ . . . 379 

CHAPTER XXII 
INFLAMMATORY DISEASES OF THE TONSIL . . „ . . . . 395 

CHAPTER XXIII 
SURGERY OF THE TONSILS 414 

CHAPTER XXIV 

NEOPLASMS OF THE TONSIL . . . . . . . . „ ... 442 



PART III 

DISEASES OF THE LARYNX 

CHAPTER XXV 
INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS 447 

CHAPTER XXVI 

PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMI- 
TIES. PROLAPSE OF THE VENTRICLES. STENOSIS. SUB- 
GLOTTIC STENOSIS ............. 500 

CHAPTER XXVII 
NEUROSES OF THE LARYNX 508 

CHAPTER XXVIII 
THE SINGING VOICE 525 

CHAPTER XXIX 
DEFECTS OF SPEECH . . . . . . . . 536 

CHAPTER XXX 
NEOPLASMS OF THE LARYNX 544 

CHAPTER XXXI 

FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND 
ESOPHAGUS ,...,,,.,. 577 



x CONTENTS 



PART IV 
THE EAR 

CHAPTER XXXII 
THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR . . 601 

CHAPTER XXXIII 
THE FUNCTIONAL TESTS OF HEARING 616 

CHAPTER XXXIV 
GENERAL ETIOLOGY OF DEFECTIVE HEARING 630 

CHAPTER XXXV 

FOREIGN BODIES IN THE EAR. CERUMINOUS PLUGS IN THE 

MEATUS 635 

CHAPTER XXXVI 
MALFORMATIONS AND NEOPLASMS OF THE AURICLE ... 645 

CHAPTER XXXVII 
DISEASES OF THE AURICLE AND EXTERNAL MEATUS ... 654 

CHAPTER XXXVIII 
MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI 669 

CHAPTER XXXIX 
DISEASES OF THE EUSTACHIAN TUBES 683 

CHAPTER XL 
THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION . 692 

CHAPTER XLI 
INFLAMMATORY DISEASES OF THE TYMPANUM 703 

CHAPTER XLII 

OTOSCLEROSIS; SPONGIFYING OF THE BONY CAPSULE OF THE 

LABYRINTH 735 



CONTENTS x i 

CHAPTER XLIII 

ACUTE AXD CHRONIC SUPPURATIVE OTITIS MEDIA. CHOLES- 
TEATOMA .......... 742 

CHAPTER XLIV 

THE SEQUELAE OF SUPPURATIVE OTITIS MEDIA, MASTOIDITIS, 
AXD CHOLESTEATOMA. SUPPURATION OF THE LABY- 
RINTH 765 

CHAPTER XLV 

PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS 

IN SUPPURATIVE OTITIS MEDIA ......... 774 

CHAPTER XLVI 
GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS . 784 

CHAPTER XLV1I 

, INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF OTITIC 

ORIGIN 789 

CHAPTER XLVIII 
SURGERY OF THE TEMPORAL BONE . . „ . . . . . . . 819 

CHAPTER XLIX 

THE LABYRINTH: ITS PHYSIOLOGY, FUNCTIONAL TESTS AND 

DISEASE 861 

CHAPTER L 
LABYRINTHITIS: ILLUSTRATIVE CASES 917 

CHAPTER LI 
SURGICAL DISEASE OF THE LABYRINTH 926 

CHAPTER LII 
SURGERY OF THE LABYRINTH 953 

CHAPTER LIII 
FACIAL PARALYSIS . 993 

CHAPTER LIV 
NON-SURGICAL DISEASES OF THE LABYRINTH 1000 

CHAPTER LV 
DEAF-MUTISM 1023 



DISEASES OF NOSE, THROAT, AND EAE 



PART I 
THE NOSE AND ACCESSORY SINUSES 



CHAPTEE I 

THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE 
AND ACCESSORY SINUSES 

THE NOSE 

The Nasal Chambers. — The nose is divided, by the nasal septum, 
into two chambers, the right and the left. The nasal chambers are for 
respiratory, olfactory, phonatory, and gustatory purposes. The inspira- 
tory current passes upward from the vestibules to the middle and superior 
meatuses, and is thence deflected downward and backward by the 
middle turbinals and the roof of the nose to the choanse, into the epi- 
pharynx. The expiratory current is deflected from the vault of the 
epipharynx into the choanal, and thence forward through the middle 
and inferior meatuses to the vestibules of the nose. (Fig. 2). 

The practical clinical application of the foregoing facts lies in the 
different effects of stenosis in the inferior and in the superior portions 
of the nasal chambers. An obstructive deformity of the lower portion 
of the septum may interfere somewhat with the expiratory current, as 
it blocks the inferior meatus while the middle and superior meatuses 
are free, and the expiratory current, therefore, passes through the nasal 
chamber upon the obstructed side, with but little or no impediment. 
The obstruction in the lower portion of the nasal chamber does not 
materially interfere with the inspiratory current, as its course is normally 
higher in the nasal passage. There are exceptions, however, to this rule. 
If, for example, the deformity of the septum extends well forward into 
the vestibule of the nose it will materially interfere with the inspiratory 
current, as it blocks the entrance to the nose. (See Chapter IV.) • 

The Septum. — This subject is fully discussed in connection with the 
deformities and malformations of the septum. (See Chapter IV.) 

The Turbinated Bodies. — The turbinated bodies, three in number. 
are located upon the outer wall of the nasal chambers, and are known 
2 (17) 



18 THE XOSE AXD ACCESSORY SINUSES 

as the inferior, middle, and superior turbinated bodies (Fig. 2), of which 
only the inferior and middle are of clinical importance. These are 
characterized by the presence of venous plexuses in the submucous tissue 
of the membrane, known as "swell bodies," or the erectile tissue of the 
nose. The erectile tissue is chiefly distributed along the inferior border of 
the inferior turbinal, and on the posterior ends of the inferior and middle 
turbinals. Its function is supposed to be that of warming the inspired 
air and of regulating the amount of serous secretion. Either process is 
of vital importance to the lower respiratory tract. The lower respira- 
tory tract does not secrete enough moisture for physiological purposes 
(protective), nor is it capable of warming the inspired air sufficiently 
to bring it to the body temperature without injury to its mucous mem- 
brane. It is important that the heating and humidifying apparatus of 
the nose should be in good physiological condition. When, therefore, the 
vasomotor nerves which regulate the erectile tissue are disturbed in their 
function, the preparation of the inspired air for the lower air tract is 
imperfectly performed. The lower air tract is exposed to the irritating 
influence of the inspired air, and irritation of the lining mucosa and of 
the endothelial cells which line the air vessels of the lungs may result in 
bronchitis, while the transfusion of the gases, oxygen, and carbon dioxide 
may be disturbed in the air vesicles. The processes of tissue metabolism 
or the chemistry of nutrition are perverted. 

In addition to the foregoing conditions resulting from the disturbed 
functions of the "swell bodies," the patient may experience either a 
sense of "stuffiness" of the nose or of a foreign body, or the reverse, an 
unduly open nose. If, for example, there is an anterior or vestibular 
obstruction from any cause, the negative pressure thus brought about 
causes an engorgement of the "swell bodies," with the resultant dis- 
agreeable symptoms already described. This condition is known as 
rhinitis with turgescence. If, on the contrary, the patient is anemic, the 
"swell bodies" may become collapsed and the nasal chambers unduly 
patulous. This condition is known as rhinitis with collapse of the erectile 
tissue. The turbinated bodies are of clinical interest, for the further 
reason that they divide the nasal chambers into three partial chambers 
or meatuses. The inferior meatus is the space between the floor of the 
nose and the inferior turbinal. The middle meatus is the space between 
the inferior and middle turbinals. The superior meatus is the space 
above the middle turbinal. The meatuses are of great clinical interest 
on account of the accessory nasal sinuses opening into them. 

The Meatuses. — The inferior meatus is of clinical importance, as the 
nasal orifice of the tear duct opens in its anterior portion, and because it 
is a part of the expiratory air tract. 

The Middle Meatus. —The middle meatus is of great clinical impor- 
tance because the frontal, anterior ethmoidal, and the maxillary sinuses 
open into it. The frontal and the anterior ethmoidal cells drain into the 
infundibulum in 50 per cent, of the cases. The bulla ethmoidalis and 
the cells in the middle turbinal do not drain into the infundibulum, 
but open directly into the middle meatus. The bulla is often quite 



THE NOSE 19 

large and bulges so much toward the septum that it encroaches upon 
the infundibulum and entirely obstructs it. It thereby interferes with 
the drainage of the frontal, maxillary, and the anterior ethmoidal cells. 
The cells opening into the middle meatus are referred to for convenience 
as Series I. 

When pus is present in the middle meatus it is significant of empyema 
of one or more of the cells comprising Series I, namely, the frontal sinus, 
the anterior ethmoidal, and the maxillary sinuses (antrum of Highmorej. 

The Superior Meatus. — The superior meatus is of clinical interest 
because the posterior ethmoidal and the sphenoidal cells (Series II) 
open into it. This meatus cannot be directly inspected on account of 
its hidden position above the middle turbinal. It may, however, be 
examined with a probe. When pus flows into it from the posterior 
ethmoidal and sphenoidal sinuses, and the olfactory fissure is not com- 
pletely closed, it may be seen lying between the septum and the middle 
turbinal (the olfactory fissure). 

The superior meatus is of still further clinical interest because the 
terminal filaments of the olfactory nerve are distributed there. (See 
Olfactory Nerves.) 

The Sinuses Residual Organs. — The nasal accessory sinuses in man 
are the remains of the olfactory organ, hence they have a low recupera- 
tive power after operations. I have repeatedly observed the slow and 
sometimes incomplete repair after operations, even after the most 
thorough exenteration, especially of the ethmoidal cells. I attribute 
this to the fact that the structures in man have ceased to perform the 
function they were originally designed to do. Through long ages of 
retrogression the tissues have lost some of their vitality and do not 
regenerate with the same degree of vigor as those structures which 
still perform their functions. 

The Nerve Supply of the Nose. — The Sensory Nerves. — The sensory 
nerves of the nasal septum, the N. ethmoidalis anterioris and the N. 
nasopalatine, send their filaments to the anterior and posterior por- 
tions of the septum, respectively. The N. ethmoidalis anterioris passes 
through the anterior portion of the cribriform plate (Fig. 1), thence for- 
ward and downward to the vestibule. The N. nasopalatinus extends 
forward and downward on the septum to the canalis incisivus, anas- 
tomoses with that of the other side, and ends in the mucous membrane 
of the hard palate. 

The sensory nerve supply of the outer walls of the nose is derived from 
the N. ethmoidalis anterioris and from branches of the ganglion spheno- 
palatinum. The N. ethmoidalis anterioris supplies the anterior portion 
of the lateral walls in front of the turbinated bodies, and the turbinated 
bodies are supplied by branches of the sphenopalatine ganglion (Fig. 2). 
The hard and soft palates are also supplied from this ganglion. These 
anatomical facts may be utilized in injecting cocaine for anesthetic 
purposes (Killian) and in injecting alcohol in the treatment of hyper- 
esthetic rhinitis (O. J. Stein). 

Vasomotor branches are also supplied to the vessels of the mucous 



20 



THE NOSE AND ACCESSORY SINUSES 



membrane and erectile tissue of the turbinated bodies from the ganglion 
sphenopalatinum, and are under the control of the vasomotor centres of 



Fig. 1 




Nerve supply of the septum nasi: a, N. ethmoidals anterioris; 6, N. olfactorii; c, N. nasopalatine; 
d, canalis incisivus. (After Spalteholz.) 

Fig. 2 




Nerves of the lateral wall of the nose: a, ganglion sphenopalatinum; b, rami nasales posteriores 
superiores laterales; c, rami nasales posteriores inferiores laterales; d, Nn. palatini; e, Nn. olfactorii; 
/, rami nasales interni, N. ethmoidalis anteriores. (After Spalteholz.) 

the medulla; there is probably a connection with the nuclei of the vagus 
through association fibers (Watson Williams). 



THE NOSE 21 

The distribution of the accessory nerves over the septum and the outer 
walls of the nose, and especially the branches from the sphenopalatine 
ganglion over the turbinate, at once suggests the reason for the sensitive- 
ness of these areas when the mucous membrane is inflamed, or is so 
swollen that it impinges against the septum. It also suggests the reflex 
phenomena, as asthma, often observed when there is inflammation or 
other disease of these regions. The association fibers, referred to above, 
connecting the sphenopalatine ganglion with the vagus establish a 
physiological relationship between the upper and the lower respiratory 
tracts, hence the asthma of nasal origin. I have repeatedly seen cases 
in which the asthma promptly disappeared after the removal of nasal 
polypi, or after an exenteration of the ethmoidal labyrinth for sinuitis. 
The irritation of the terminal filaments of the turbinal branches from 
the sphenopalatine ganglion was thus removed, and the reflex stimulus 
through the ganglion to the vagus and thence to the bronchial muscles 
ceased to be given ofT; hence, the bronchial spasm (asthma) was cured. 

The vascular engorgement present in chronic rhinitis with turgescence 
is due to a paresis of the vasomotor constrictor muscles supplied by the 
branches of the sphenopalatine ganglion. 

The Olfactory Nerve. — The olfactory nerve descends through the lamina 
cribrosa (cribriform plate) from the under surface of the olfactory bulb 
and is distributed in the mucous membrane covering the upper portion 
of the superior turbinal and a corresponding portion of the septum 
(Figs. 1, 2, and 3). Formerly it was thought that the distribution of 
the olfactory nerve in man covered a much more extensive area, the 
upper and median surfaces of the middle turbinal and a corresponding 
area of the septum being included in the alleged area of distribution. In 
many of the lower animals the nerve has a wider distribution; the sinuses 
communicate more freely with the nasal chambers and are utilized for 
the spread of the terminal olfactory nerve filaments. In man they are 
the remains of the organ of smell, and only communicate with the nasal 
cavities through small ostei or cell openings, as they are no longer needed 
for olfaction. 

To return to the olfactory nerve. It is obvious that if the middle tur- 
binal and the septum are in apposition, the inspired air does not reach 
the olfactory region, and anosmia or loss of the sense of smell results. It 
follows that if the obstruction to the olfactory fissure is overcome, either 
by the removal of the middle turbinal or by the correction of the devia- 
tion of the septum, air is admitted to the olfactory region and the sense 
of smell is restored, provided the nerve has not undergone degeneration. 

Inasmuch as the distribution of the olfactory nerve is limited to the 
superior turbinal and the corresponding portion of the septum, the 
middle turbinal and the ethmoidal cells may be removed in their entirety 
without interfering with its distribution. In such operations the superior 
turbinal should be left intact in so far as it is compatible with a com- 
plete exenteration of the ethmoidal cells. 

The Blood Supply of the Nose.— The middle meningeal artery 
gives off the sphenopalatine branch, which, when it reaches the posterior 



22 THE NOSE AND ACCESSORY SINUSES 

portion of the lateral wall of the nose, subdivides into the lateral pos- 
terior nasal arteries. These are distributed over the middle and inferior 
turbinals and the middle and inferior meatuses. The superior tur- 
binal and the anterior portion of the outer wall of the nasal chamber 
are supplied by the posterior ethmoidal and the anterior ethmoidal 
arteries respectively (Plate I, Fig. 1). 

As the posterior lateral nasal arteries are of considerable size, it is to 
be expected that the removal of either the middle or inferior turbinated 
bodies may be attended by considerable hemorrhage. As a matter of 
fact, the removal of the middle turbinal is usually followed by more or 
less bleeding for twenty-four hours. There is a free anastomosis be- 
tween the lateral nasal arteries and the anterior ethmoidal artery; hence, 
after the removal of the turbinated body bleeding may come from both 
sources though but one artery is injured. 

The septum is supplied by the A. nasales posteriores septi, a branch 
of the A. sphenopalatina, through the foramen sphenopalatinum. It 
has three main branches : one supplies the posterior, another the inferior, 
and the other the middle and posterior portions of the septum. 

The A. ethmoidalis anterior and the A. ethmoidalis posterior are 
distributed to the anterior and the superior portions of the septum 
(Plate I, Fig. 2). Severe hemorrhage occasionally attends or follows an 
operation upon the septum, especially when the operative field includes 
the middle branch of the A. nasales posteriores septi. 



THE PHYSIOLOGY OF THE NOSE 

The functions of the nose are olfactory, phonatory, respiratory, gusta- 
tory, and the ventilation of the nasal accessory sinuses. The gustatory 
function in man is probably of least importance, the olfactory of sec- 
ondary importance, the phonatory of tertiary importance, while the 
respiratory, and ventilating functions are of the greatest importance. 

The Sense of Smell. — The olfactory nerve, or organ of smell, is 
located in the upper portion of the nasal chambers. The olfactory 
nerve (Fig. 3) is distributed over the attic of the nose as far downward 
as the upper margin of the middle turbinated body and on the septum 
over a corresponding area. A knowledge of the area of distribution of 
this nerve is of practical importance in the diagnosis, prognosis, and 
treatment of certain diseases of the nose. If there is anosmia, or loss of 
the sense of smell, the question arises as to whether the impairment is 
due to a degenerative change in the nerve itself, or to an obstruction 
to the entrance of the odoriferous particles or emanations to the terminal 
cells of the olfactory nerve. 

The lesions may, however, be intracranial, in which case there may be 
no evidence of either an obstructive lesion or of degenerative changes 
in the attic of the nose. 

The loss of the sense of smell, while not comparable to the loss of the 
nasal respiratory function, is, nevertheless, attended by considerable 







The Arterial Supply of the Lateral Wall of the Nose. 

A, a. meningea anterior; B, a. ethmoidalis anterior; C, a. ethmoidalis posterior; D, aa, 
nasales posteriores laterales ; E, a. sphenopalatina; F, aa. palatini major et minores. 

FIO. 2 




The Arterial Supply of the Septum Nasi. (After Spalteholz. 



A, a. ethmoidalis anterior; B, a. ethmoidalis posterior: C, aa. nasales posteriores septi 
D, anastomosis with a. palatina major. 



THE PHYSIOLOGY OF THE XOSE 



23 



inconvenience. The pleasure experienced by the recognition ot certain 
odors is longed for by those affected by anosmia. More than this, they 
have lost one of the senses whereby they are protected from harm by 
certain substances, as ammonia, etc. By its aid we are warned of the 
near approach of decaying matter, or other foul-smelling and unsanitary 
substances. In the lower animals the sense of smell is of much greater 
utility in seeking food and in detecting the approach of hunters and 
animals intent upon their destruction. 

Phonation. — The function of the nose in speaking and singing is so 
important that Jeane de Reske has said that the more he studies the 
voice the more he is convinced that it is a question of the nose. I have 
often noted that popular 

public speakers had well- Fiq. 3 

developed nasal resonance, 
while speakers lacking reso- 
nance had difficulty in hold- 
ing the attention of their 
audiences. While the initial 
tone is produced by the vibra- 
tions of the vocal cords, the 
voice is decidedly unpleasant 
and unmusical if it is not 
rich in overtones from the 
resonance chambers of the 
nose, throat, and chest. (See 
The Singing Voice.) The 
nasal chambers and accessory 
cavities are of prime im- 
portance in voice production, 
and any obstruction from 
swelling of the mucous mem- 
brane, deflection, or other 
lesion of the septum so 
materially alters the quality 
of the voice as to make it 
disagreeable and inartistic. 

Nasal Respiration. — As 
before stated, the respiratory 
function of the nose is the most important 
more than mere tubes through which air is drawn into the 
produce certain changes in the air which prepare it so that the normal 
transfusion of oxygen and carbon dioxide may take place through the 
walls of the air vesicles. The respiratory functions of the nose are 
threefold, namely: (a) To temper, (b) humidify, and (c) filter the 
inspired air. 

Experiments have demonstrated that no matter what the temperature 
of the air may be before it is inhaled, it is raised or lowered, as the case 
may be, to near the body temperature. The delicate structures of the 




Showing the area of distribution of the olfactory 
terminal nerve cells in the human nose. The triangular 
flap is the septum turned upward; the area of distribu- 
tion is limited to the region of the superior turbinal, 
and a corresponding area of the septum, the middle 
turbinal receiving few or no olfactory cells. 



The nasal chambers are 

ungs; thev 



24 THE NOSE AND ACCESSORY SINUSES 

deeper respiratory tract are thereby protected against the great varia- 
tions and extremes of temperature. 

It has also been shown that the air in passing through the nasal cham- 
bers receives moisture from the nasal mucous membrane. The mucosa 
of the lower respiratory tract and the epithelial walls of the air vesicles 
of the lungs are thus protected from the varying humidity of the atmo- 
sphere. In passing through the nose the air is raised (usually) in tem- 
perature, thus expanding it and increasing its capacity to absorb moisture. 
The "swell bodies," or erectile tissue of the nose, and the serum-secreting 
glands of the nasal mucosa give off moisture, which is rapidly taken up 
by the expanded air and carried to the lower respiratory tract, where 
the serum-secreting organs are much less developed. It has been esti- 
mated that approximately one pint of serum is thus transferred from the 
nasal cavities to the lower respiratory tract in twenty-four hours. 

The part of the nasal structures which secrete most of the serum is 
generally supposed to be the "swell bodies," or erectile tissue, located 
chiefly along the free border of the inferior turbinated bodies, and on 
the posterior ends of the middle and inferior turbinated bodies. The 
latter portions sometimes become enlarged and form the so-called 
mulberry hypertrophies. It is probable that the mucous glands also 
secrete some of the serum. The "swell bodies" are under the control 
of the vasomotor nervous system, which, under normal conditions, 
regulates the supply of moisture to meet the demands. If the air is dry 
the " swell bodies" enlarge and become just active enough to fully saturate 
the expanded air in the nose; whereas if the atmosphere is humid they 
are less active. When an obstructive lesion, or catarrhal inflamma- 
tion, is present the "swell bodies" and glands do not respond normally 
to the atmospheric conditions, hence the air is not properly humidified 
in its passage through the nose. The treatment of these conditions 
should be, therefore, so directed as to restore the "swell bodies" and 
glands to their normal activity. In order to do this, it may be necessary 
to give stability to the vasomotor nervous system by judicious bathing, 
outdoor exercise, etc. In addition, local massage of the mucous mem- 
brane and other treatment may be necessary. Surgical interference 
should always be accomplished with respect to the location of the "swell 
bodies," care being exercised to avoid their destruction, except in those 
cases in which they have undergone considerable hypertrophy. The 
surgery of the middle turbinated body may be practised with much 
greater freedom, because it does not have so much to do with the respira- 
tory functions of the nose. The inferior turbinated body, however, 
should be treated surgically only when its secretory function is largely 
destroyed, or when it is so enlarged by hypertrophic or hyperplastic 
changes that it obstructs nasal respiration. 

That the nose is a filter is evident upon inspection of the secretions 
and the vibrissa? of the vestibule, as they are loaded with dirt. The 
vibrissa? guarding the atrium of the nostrils act as a coarse filter, the 
larger particles lodging on them, the smaller ones entering the nasal 
cavities, where they are caught upon the irregular surface of the moist 



THE PHYSIOLOGY OF THE NOSE 25 

mucous membrane. The lower air tract is thus protected from the 
irritation which would otherwise result. F. C. Cobb, under the direction 
of Frederick Coolidge, of Harvard University, has shown by a long 
series of experiments that the secretions posterior to the vestibules of the 
nose are sterile, thus demonstrating the great physiological importance 
of the vibrissas and the sterilizing quality of the nasal secretions. 

The Gustatory Function of the Nose. — The real gustatory or 
taste sense (sweet, sour acid, bitter, and salt) is supplied by the dis- 
tribution of the glossopharyngeal and the fifth nerves to the fauces and 
the base of the tongue, whereas the delicate flavors which give so much 
pleasure to the consumption of foods and drinks are appreciated through 
the olfactory nerve. If the nostrils are closed and the eyes covered it 
is almost impossible to distinguish between coffee and water of the 
same temperature, as the aromatic flavor cannot be appreciated by the 
nose when closed. 

Ventilation of the Sinuses. — I have assumed a fifth function of the nose 
— the ventilation of the accessory sinuses — which has not heretofore 
been described under the physiology of the nose. It is obvious to anyone 
who has had an abundant opportunity of observing inflammation of the 
sinuses, that ventilation is a prime requisite for the maintenance of the 
mucous membrane of these cavities in a healthy condition. Any inter- 
ference with the ventilation of these cavities lowers the resistance of the 
mucous membrane and the diminished amount of oxygen allows the 
secretion to undergo rapid decomposition. 

Summary: The functions of the nose are fivefold, namely: 

1. Olfactory, located in the attic of the nose. 

2. Phonatory, enriching the voice by overtones. 

3. Respiratory. 

(a) The air is warmed or tempered to or nearly to the body tempera- 
ture in passing through the nose, thereby preventing shock and irritation 
to the mucosa and air vesicles of the lower respiratory tract. 

(b) The air is expanded by the warmth of the nasal chambers, and 
its capacity to absorb the moisture thrown off by the " swell bodies" and 
mucous glands is increased. The mucosa and air vesicles are thus 
moistened, or, at least, their moisture is not absorbed (the air being 
already saturated in its passage through the nose), and irritation is 
prevented. The nose keeps the inspired air in a state of saturation. 

(c) The air is filtered in its passage through the nose by the vibrissa? 
and the moist mucous membrane. The irritation to the mucosa and 
air vesicles which would otherwise occur is thus prevented. 

4. The gustatory (olfactory) sense complements the sense of taste. 

5. The ventilation of the accessory sinuses maintains the normal 
resistance of the mucous membrane and prevents the rapid decompo- 
sition of the secretions. 



CHAPTEE II 

THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL 

MEDICINE 

The writings of William Meyer, of Copenhagen, William Daly, of 
Pittsburg, and E. P. Friedreich, of Leipsic, have given a breadth to 
rhinology, laryngology, and otology which they did not have in the days 
when practice along these lines was regarded as a ''specialty." With 
this broader view they are now regarded as the pursuit of the practice 
of general medicine and surgery, with special reference to the diagnosis 
and treatment of diseases in general, and those of the nose, throat, and 
ear in particular. 

A proper comprehension of the relation of the nose, throat, and ear 
to general medicine and surgery will be facilitated by a brief analysis 
of the interdependence and coordination of the various organs and parts 
of the body. 

ELEMENTARY FACTS 

(a) The Breathway. — The upper respiratory tract is the channel in 
which the air is prepared for the interchange of gases which takes place 
in the air vesicles of the lungs. The nose is especially concerned in the 
process of humidifying, warming, and filtering the inspired air, and it 
is obvious that any disease or obstruction that interferes with these physio- 
logical processes will affect the transfusion of gases through the capillaries 
of the walls of the air vesicles. The absorption of oxygen by, and the 
elimination of carbon dioxide from, the blood will not occur in normal 
ratio. The blood will be deficient in oxygen and surcharged with 
carbon dioxide. As oxygen is essential to the processes of assimilation 
* and nutrition, its lessened quantity in the blood gives rise to certain dis- 
turbed conditions of the digestive, the assimilative, and the nutritive 
functions. The presence of an excess of carbon dioxide also adds to these 
disturbances. It is well known that the excessive accumulation of 
carbon dioxide in the blood acts as a poison to the leukocytes, thus inter- 
fering with their functional activity. A normal amount of carbon dioxide 
in the blood favors the assimilative, nutritive, and leukocytic processes, 
and it is only after a greatly increased amount of it is present that there 
are marked disturbances. It not only interferes with the activity of the 
leukocytes, but also with other cellular structures of the body "as well. 
The combined effect, therefore, of an increased amount of carbon 
dioxide and a diminished quantity of oxygen in the blood is to pro- 
duce general anemia, indigestion, malassimilation, malnutrition, and 
infectious processes. 
(26) 



ELEMENTARY FACTS 27 

The xanthin group of toxins, including indican, are thrown into the 
circulation and give rise to certain nervous phenomena, as restlessness, 
peevishness, headache, mental depression, aprosexia, and a general 
feeling of malaise. 

The digestive disturbances are still further increased by the ingestion 
of the infected secretions from the epipharynx and the tonsils. Putre- 
factive as well as pathogenic bacteria are swallowed with the secretions 
from the nose and throat, and give rise to what is commonly known as 
chronic dyspepsia, or indigestion. It is probable that the putrefactive 
germs are more potent in this connection than the streptococci and the 
staphylococci. The conditions of the nose and throat which most com- 
monly give rise to this kind of discharge are nasal stenosis, atrophic 
rhinitis, chronic rhinitis, sinuitis, epipharyngeal catarrh, and chronic 
follicular tonsillitis. 

There are certain conditions of the stomach and of the intestinal 
tract which affect the mucous membrane of the upper respiratory tract. 
If, for example, there is chronic indigestion, there is also malassimilation 
and faulty metabolism. The imperfect products of indigestion are in- 
completely oxidized and are thrown into the circulation, where they irri- 
tate the mucous membrane of the nose, as well as the vasomotor nerves, 
thus causing local congestion and overnutrition. The secretions of 
the glands of the mucous membrane of the upper respiratory tract are 
also thereby modified, thus predisposing to, or at least intensifying, the 
catarrhal disease present. In the same way hyperacidity and subacidity 
of the stomach may indirectly irritate the mucosa of the nose and throat. 
One of the most potent influences exerted by the products of indigestion 
is through the reflex nervous system, pharyngitis, hypersensitiveness, 
sneezing, etc., being the direct expression of this condition. 

In atony of the stomach there is a putrefactive formation of gases, 
which act reflexly and through the circulatory system on the mucous 
membrane of the upper respiratory tract and cause phenomena quite 
similar to those just mentioned. Another condition which is quite 
similar in many respects to the foregoing is that which occurs in gout or 
lithemia. In connection with this disease the larynx and the pharynx 
are particularly affected. In the pharynx there may be itching behind 
the pillars of the fauces, associated with a similar irritation in the external 
meatus of the ear. Some observers regard these signs as characteristic 
of gout. 

When such symptoms appear, the administration of calomel and the 
bicarbonate of soda, followed in twelve hours by a saline purge, will 
give marked relief. After this, teaspoonful doses of the phosphate of 
soda should be given two or three times daily for a few weeks. 

Vomiting and eructation of gases from the stomach exert an irritating 
effect upon the mucous membrane of the pharynx, the epipharynx, 
and the nose. The irritation is due to biochemical as well as mechanical 
causes. Catarrhal inflammation in the epipharynx is thus perpetuated, 
and may finally extend to the Eustachian tube and the middle ear, and 
cause tinnitus and deafness. 



28 THE NOSE AND ACCESSORY SINUSES 

(b) Intimate Relations between Organs. — All the organs of the body 
are more or less intimately connected by the vascular, the lymphatic, 
and nervous systems, hence disturbances in one more or less affect 
the others. The bloodvessels and the lymph channels carry toxic and 
infective material to all the organs of the body, including the nose, 
throat, and ear, and thus influence the functional and the pathological 
processes in these organs. While the data considered under this subject 
somewhat overlap those considered under («), it is well, nevertheless, 
to emphasize certain features more prominently in this connection. 

Anemia is a condition of the blood due to various causes, and often 
gives rise to collapse of the erectile tissue of the nose. This is usually 
spoken of as "rhinitis with collapse of the turbinated bodies." (See 
Rhinitis with Collapse of the "Swell Bodies.") 

On the other hand, another condition of the nasal mucous membrane 
which may cause anemia instead of being a result of it, as related in the 
preceding paragraph, is atrophic rhinitis. It is characterized by anemia 
which is probably due to the absorption of toxic material from the nose, 
and to the loss of the respiratory functions of the nose. 

If the lymphatic vessels are charged with infective material, which is 
finally transferred to the bloodvessels and tissues of the entire body, a 
state of general toxemia is induced, the nose, throat, and ear participating 
in the disturbed processes. On the other hand, one of the commonest 
clinical pictures is that wherein the lymphatic glands are enlarged by 
suppurative disease of the ear, nose, and throat. This subject is dis- 
cussed more fully in the chapter on the Clinical Anatomy of the Tonsils. 
I wish, however, to emphasize the influence of suppurative diseases 
of the ear upon the lymphatic glands of the neck. As the ear is more 
intimately connected with the lymphatic glands of the posterior triangle 
of the neck, it is to the glands in this region that we should look for 
enlargement in inflammatory disease of this organ. 

The close approximation of the mucous membrane of the nose and 
ear to the contents of the cranial cavity may also give rise to serious 
consequences by the conveyance of infective material thereto. Brain 
abscess, meningitis, septic thrombophlebitis, etc., may be thus caused, 
although the usual channel of invasion is through a necrotic area in 
the floor of the cranial cavity. 

The nervous system, when disturbed in its function, necessarily influ- 
ences the upper respiratory tract, as well as other parts of the body. 
We may thus have vasomotor rhinitis and asthma, as well as certain 
functional disturbances of the ear and the larynx as a result of a disturb- 
ance of the general nervous system. 

Hysteria probably comes under this heading, and while it is not 
demonstrable histologically, it may have a histological basis. Hysteria 
of the nose, throat, and ear, as in other parts of the body, is characterized 
by a disturbance of those functions which are more particularly under 
the control of the mind, the involuntary functions not being affected. In 
the larynx, for instance, the normal respiratory movements are not dis- 
turbed, as they are involuntary; whereas the movements of the larynx 



ELEMENTARY FACTS 29 

which are concerned in the production of speech, being under the 
control of the mind, are voluntary, and are affected. 

Hay fever, laryngeal cough, sneezing, bronchial asthma, anesthesia 
and hyperesthesia of the mucous membranes of the ear, nose, and throat 
are reflex phenomena, which may result from the irritation of the nervous 
svstem by the toxic material in the circulation. 

Another very important disease generally regarded as due to infection 
of the blood is rheumatic fever, or acute articular rheumatism. The 
gateway of infection is often through the tonsils, or some portion of 
Waldeyer's ring. The throat symptoms of this disease are a reddened 
pharynx, with a defined or circumscribed inflammation of the larynx, 
redness and swelling in the arytenoid region, and sometimes fixation 
of the arytenoid cartilages. Pain and difficulty in phonation and deg- 
lutition may also be present in rheumatic fever. The physician should 
not only look upon the tonsils as the portals of infection, but he should 
look to the pharynx and larynx for some symptoms of the rheumatism. 
Acute rheumatic fever also gives rise to certain symptoms which are 
not commonly recognized. For example, it may cause nosebleed in 
children, and in some cases is undoubtedly the cause of chorea. 

Malaria is another disease affecting the blood which gives rise to 
certain symptoms in the ear, nose, and throat. Mastoid pain, and, 
indeed, mastoid suppuration, has been observed in which the malarial 
element was prominent. In view of some recent observations, it may 
be questioned, however, whether these cases were distinctly malarial 
in their origin. We now know that there are certain septic conditions 
which give rise to symptoms so nearly like those due to the plasmodium 
of malaria that it may be questioned whether these cases were truly 
malarial, or whether they were septic. It is known, however, that the 
malarial poison may cause nasal hydrorrhea and vasomotor rhinitis. 

The bloodvessels and lymphvessels are channels of communication 
between the throat and the appendix. In certain cases of appendicitis 
it has been shown that streptococcus infection was present both in the 
throat and in the appendix. Another possible source of communication 
in these cases is through the alimentary tract. 

(c) The Digestive Tract. — The digestive tract, which prepares the 
food for tissue building, is affected by the putrefactive and the patho- 
genic microorganisms from the nose, throat, and ear. The primary 
treatment should be addressed to the relief of the diseased condition of 
the upper respiratory tract, rather than to the stomach and the intestines. 
The presence of dyspepsia, or other functional disturbances of the 
stomach and the intestines, should lead to the examination of the nose 
and throat, with special reference to the discharges from them, which 
may be swallowed by the patient. On the other hand, if there is an irri- 
table state of the nasal, pharyngeal, and laryngeal mucous membranes, 
which is not explained by any local source of irritation, careful attention 
should be given to the condition of the stomach and the intestines, or to 
the organs of digestion and assimilation in general, with a view to deter- 
mining whether they are properly performing their functions. If thej 



30 THE NOSE AND ACCESSORY SINUSES 

are not, the nutritive properties of the food are thrown into the circula- 
tion imperfectly or insufficiently prepared for their purposes. The 
irritation thus carried to the nasal mucous membrane and to the nerves 
supplving it may be the chief cause of the local disturbances. It is obvious 
that under these circumstances the treatment should be addressed to 
the correction of the disorders of the digestive tract, rather than to the 
nose, throat, and ear. 

(d) Excretory Organs. — The function of the excretory organs is to 
throw off the refuse material formed during the processes of nutrition. 
The refuse consists not only of the material not needed for the nutrition 
of the body, but also of the toxic material and the half-way products 
of oxygenation already referred to. Hence, any impairment of the 
functions of these organs results in an excess of toxic material in the 
blood and the lymphatic vessels, thereby causing congestion, irritation, 
hypertrophy, hyperplasia, or altered secretions in the upper respiratory 
tract. This feature of the subject is intimately associated with those in 
the preceding paragraphs. 

The skin and the kidneys are the chief excretory organs of the body. 
We will dismiss the skin with a brief reference to the fact that eczema 
lupus, etc., affecting other portions of the body may also involve the 
external nose and external ear. Or, the pathogenic processes may begin 
with the skin of the nose or the external ear, and extend to other parts 
of the body. We will also incidentally state that erysipelas of the nose 
may involve the nasal mucous membrane, and that erysipelas of the 
skin over the mastoid process may extend to the middle ear and the 
mastoid cells, or even to the cranial cavity through the lymphatics and 
the bloodvessels of this region. 

The kidneys, however, are the excretory organs which chiefly interest 
us in this connection. They may be diseased by prolonged infection in 
remote parts of the body, as in the nasal sinuses or the alveolar processes 
—pyorrhea alveolaris. Bright's disease may manifest its earliest symp- 
toms in the mucous membrane of the throat. The throat symptom 
complained of is dryness. This same symptom may also be present in 
diabetes. Diabetes is mentioned here not because it is a disease of the 
kidneys, but because its chief symptom is to be found in the examination 
of the excretions from the kidneys. 

When a patient complains of persistent dryness of the pharynx his 
urine should be tested for albumin, casts, and sugar. In some cases 
albumin will not be found at first, but after a few years its presence may 
be detected. 

Edema of the glottis, causing laryngeal stenosis, is often due to uremia 
developing as a result of Bright's disease. In the milder forms of uremia 
bronchial asthma and hemorrhage of the upper air passages are some- 
times found to be the chief expression of the disease. In the more pro- 
nounced uremic conditions there may be aphasia from edema of the 
brain. 

(e) Proximity of Organs.— The close proximity of the organs of the 
head favors a correlated pathological activity. The eye is near the 



- 



ELEMENTARY FACTS 31 

nose and has immediate communication with it through the tear duct, 
as well as through the lymphatics, the bloodvessels, and the nervous 
system; hence disease in one often gives rise to certain symptoms in the 
other. Experiments with certain colored solutions dropped into the eye 
have shown the coloring matter within a very short time in the nasal 
mucous membrane. The instillation of bacteria yields the same results. 
Clinically, it is not uncommon to observe an inflammatory condition in 
the eye simultaneously with or following a similar process in the nose. 
I have often had cases referred to me by ophthalmologists who were 
unable to prescribe satisfactory glasses until after I had corrected the 
nasal condition, usually involving the middle turbinated body or the 
ethmoid cells. The proximity of the nose to the ear, as well as the physio- 
logical communication between them via the Eustachian tube, gives 
rise to a very intimate relation between these organs. 

It is well known that inflammation of the epipharynx sometimes extends 
through the Eustachian tube, by continuity of tissue, to the middle ear. 
This condition may develop until there is suppurative otitis media, 
mastoiditis, and even intracranial complications. Adenoids are also 
a fruitful source of mischief to the ear and the mastoid process. They 
may mechanically obstruct the Eustachian tube, or the epipharyngitis 
which almost invariably accompanies them may cause the ear disease. 
The removal of adenoids in children is often followed by immediate 
relief of deafness and of suppurative inflammation of the middle ear. 

While the stomach is not so closely related to the ear as the epipharynx, 
nevertheless it has a close pathological and anatomical connection 
through the esophagus. In vomiting, foreign matter may be forced into 
the Eustachian tube and the middle ear, and may cause otitis media 
and its attending complications. From this same organ eructations 
of gas may also cause irritation in the epipharynx and the Eustachian 
tubes. 

The nasal discharges, especially when there is empyema of the acces- 
sory sinmes of the nose, usually pass backward into the epipharynx 
and cause irritation and inflammation in this region. They also pass 
to the larynx and cause more or less trouble there. Stenosis of the nose 
interferes with the functions of that organ, and thus allows the air to 
pass into the epipharynx, the larynx, and the bronchial tubes insufficiently 
warmed, insufficiently moistened, and imperfectly filtered. Irritation 
of the mucosa of the lower respiratory tract is thus caused and gives 
rise to catarrhal inflammation. 

The ear is separated from the cranial cavity by a partition of bone 
which in places is not more than one-sixteenth to one-eighth of an inch 
in thickness. Chronic suppuration within the middle ear and the mas- 
toid cavity often results in necrosis of this thin plate of bone, thus opening 
a channel of communication between the middle ear and the cranial 
cavity. The sequels or complications of mastoiditis, such as meningitis, 
brain abscess, septic thrombophlebitis, etc., may thus result from ear 
disease. 

The nose is but slightly separated from the cranial cavity, and through 



32 THE NOSE AND ACCESSORY SINUSES 

the ophthalmic veins may cause thrombophlebitis of the cavernous 
sinus, which is usually fatal. 

(f) Infections. — Systemic infections from the upper respiratory tract 
have already been more or less considered in this chapter as well as in 
the one on the Tonsils as Portals of Infection; hence the subject will 
not be elaborated here. 

(g) The Central Nervous System. — It is obvious, inasmuch as the 
central nervous system supplies the innervation of the nose, throat, and 
ear, that in disease of the central nervous system the parts which it 
supplies must be affected. In other words, in certain diseases of the 
central nervous system some of its characteristic symptoms may be 
found in the upper respiratory tract. 

In tabes dorsalis there may be certain motor laryngeal disturbances, 
which may be either bilateral or unilateral. There may be ataxic move- 
ments of the vocal cords. Laryngeal crises, as spasmodic cough, may 
be present. 

Ear symptoms in tabes are rare. The cochlear and vestibular nerve 
endings may, however, be congested. In this event there will be dimin- 
ished or entire absence of bone conduction and hearing for the higher 
tones. Dizziness, nausea, and nystagmus may also be present in excep- 
tional cases. 

In multiple sclerosis a tremulous voice, which is easily fatigued, and 
is deep and hoarse in character, may be present. Muscular palsy of the 
laryngeal muscles is rare. The ear symptoms in this disease are tinnitus, 
and loss of hearing by bone conduction through the sclerotic degeneration 
of the nuclei. 

The symptoms found in paralysis agitans are about the same as those 
found in multiple sclerosis. 

(h) The Lymphatic System. — There are certain constitutional symp- 
toms due to infections through the lymphatic system which should be 
especially singled out, although they have already been referred to in 
Section (a) of this chapter. 

We now recognize that a fever, characteristic of childhood, which has 
heretofore been regarded as one of the ill-defined malarial infections, 
is due to an infection through the adenoid growths in the epipharynx. 
The fever usually runs an irregular course of about ten days, and is 
characterized by an afternoon temperature of 100° to 104°, with rest- 
lessness, peevishness, sharp pains through the ears at night, anemia, 
general debility, loss of appetite, coated tongue with indentations from 
the teeth, constipation, and cervical adenitis. Mouth breathing is 
not essential as a factor in causing the infection. A small amount of 
lymphatic tissue in the epipharynx is a sufficient portal for the entrance 
of the bacteria. The presence of this type of fever is almost always 
an indication for the removal of the adenoids. If the child is known to 
be tuberculous, some consideration may be given to the matter before 
removing them, for if the removal is imperfectly done, it may give rise to 
a recrudescence of the tuberculous infection, Which may extend to the 
lungs and lead to a fatal issue. 



ELEMENTARY FACTS 33 

Another disease which may express itself through certain patho- 
logical changes in the ear, nose, and throat is syphilis. The nose may 
be the primary seat of the lesion, the infection taking place in the removal 
of crusts from the septum with the finger. The tonsils are occasionally 
the seat of the primary lesion or chancre through the use of infected 
instruments in the throat. The author has seen cases in which both 
tonsils were the seat of chancre as a result of the instruments used in 
lancing a peritonsillar abscess. 

In one case there was the characteristic initial lesion in the left tonsil, 
with the cervical bubo on the same side, which was followed a few days 
later by the characteristic skin eruption. The source of the infection 
in this case was the dirty instruments used in lancing a peritonsillar 
abscess. I first saw the case six weeks after the tonsils were lanced. 
The patient had been complaining of sore throat for two or three weeks. 
The tonsils and the bubo were still very much in evidence and the erup- 
tion on the skin had just begun to shoAV. In the course of another week 
the corona veneris developed. The copper-colored eruption on the 
face showed more plainly at a distance of twelve or fifteen feet than it 
did when viewed near by. 

Secondary syphilis may manifest itself by mucous patches in the 
buccal cavity, by hyperemia of the larynx, hoarseness, and syphilitic 
coryza, with scanty, thick secretion from the nose. Syphilitic coryza 
is not always recognized by the family physician, it being regarded as a 
simple obstinate cold in the head. The scanty thick discharge, with 
stenosis of the nose, should, however, excite suspicion of the true nature 
of the disease. 

I once saw a case in which there w r as a marked arrest of development 
of the bones of the face because when in childhood the syphilitic coryza 
developed the family physician regarded it as an ordinary cold. He 
treated the patient for the same without success, and was finally surprised 
to find the nasal bones and the septum giving way. The soft palate and 
the pharynx later became involved and rapidly melted away under the 
blighting influence of the Spirochseta pallida. The patient is now thirty- 
six years old, and has the most pronounced "frog" face I have ever 
seen. Adhesive bands bind the soft palate to the pharyngeal wall, 
making it difficult for him to speak distinctly, though he is now success- 
fully engaged in business. 

The tertiary manifestations of syphilis are syphilitic pharyngitis and 
laryngitis, with a raucous voice. Syphilitic lesions of the tonsils, pre- 
senting a dirty grayish necrotic surface resembling diphtheria, are occa- 
sionally observed. Syphilitic gumma ta are not excessively destructive 
in character. Syphilitic papillomata of the tonsils and the soft palate 
are elsewhere described. 

Recent investigations have discredited the oft-repeated statement that 
the skin and the mucous membranes of the animal organism are insur- 
mountable barriers to microorganisms so long as the epithelial coat is 
intact. Bono and Frisco report that the researches undertaken at the 
Institute of Hvgiene at Palermo have established the fact that germs 



34 THE NOSE AND ACCESSORY SINUSES 

deposited on the intact skin or mucosa are found soon afterward in the 
lymphatic ganglia of the respective regions. If the germs are so numerous 
or so virulent as to overcome the resistance offered by the lymphatic 
ganglia, general infection follows. If not, there is merely a local re- 
action on the part of the ganglia, which become tumefied and undergo 
various modifications in their structure proportional to the number of 
germs which reach them. 

Diseases of the Eye Due to Nasal Lesions. — To establish the 
relationship between the nasal mucous membrane and the eye, micro- 
organisms were placed on the nasal mucous membrane both with and 
without obliteration of the nasolacrymal canal. The result of the ex- 
periments showed the penetration of the germs into the vitreous and 
the aqueous humors of the eye on the same side. (Bono and Frisco.) 

"None of the animals exhibited any signs of general infection. One 
or two colonies, at most, could be derived from the blood in the heart, 
the liver, the spleen, and the lymphatic ganglia of the neck, and occasion- 
ally from the anterior auricular, the submaxillary, the deep jugular, 
and the carotid lymphatic ganglia. This fact, considered in connection 
with the presence of large numbers of germs in the aqueous and the 
vitreous humor, and the absence of general infection, warrants the con- 
clusion that the bacteria penetrated directly into the eye from the nasal 
and the conjunctival mucous membranes, and that they also arrived 
secondarily in the eye through the blood, but reduced in numbers and 
virulence. Part of the germs were retained by the ganglia connected 
with the anterior lymphatic vessels of the eyeball and its appendages. 
In further experiments with instillations of India ink it was possible to 
trace the exact route followed by the particles from the conjunctival 
lymphatics along Schlemm's canal into the anterior chamber and thence 
into the vitreous. From the lymphatics of the nasal mucosa the particles 
passed into the ethmoid cells and the lamina papyracea, thence into 
Tenon's capsule, and on into the eyeball. The practical results of these 
researches are particularly important in the pathology of the eye." 

F. Mendel, after observing many cases, comes to the conclusion that 
the nasal infection and inflammation is transferred to the eye by the direct 
connection or continuance of the epithelium of the nasal mucous mem- 
brane to the conjunctiva, as well as by the intimate vascular association. 

The ophthalmic artery gives off the anterior ethmoidal, which supplies 
the nose and the lacrymal canal. The venous supply of the nasal mucous 
membrane, by means of the lacrymal plexus, is in direct communication 
with the ophthalmic vein. 

Heber Nelson Hoople, in a paper read before the American Laryn- 
gological, Rhinological, and Otological Association, in 1901, advances 
the theory that faulty pressure within the nose can cause asthenopia 
of both the ciliary and external ocular muscles. That is, mechanical 
pressure in a limited area of the nose, called by Mackenzie the reflex 
area, can cause muscular asthenopia. By muscular asthenopia he 
means the impairment of the efficiency of the ocular muscles in the 
performance of their ordinary functions. 



ELEMENTARY FACTS 35 

The pressure to which Hoople refers is confined chiefly to the middle 
turbinal, especially in great enlargement of the middle turbinated body. 

A concomitant symptom usually occurring in conjunction with the 
asthenopia is a browache or headache referred to the frontal region or 
to the occiput in rare instances. 

He cites a number of cases in his own practice and in that of others 
in which the asthenopia disappeared as soon as the nasal pressure was 
overcome. The asthenopic cases referred to belong to the so-called 
normal type rather than to the excessive type. 

He concludes that a moderate amount of pressure or mechanical irri- 
tation of the middle turbinated body against the adjacent septum will 
temporarily impair the function of the ciliary muscle; to a lesser or more 
variable degree it will also impair that of the external ocular muscles. 
If mechanical irritation (from congestion or swelling of the soft tissues) 
can impair the functions of these muscles, how much more would a con- 
tinuous pressure from a septal spur or other deviation of the septum 
digging into the middle turbinal keep up this impairment. 

The reason for the association of headache with asthenopia is that they 
have a common cause — pressure upon the sensorimotor branches of the 
trigeminus. So far as the sensory part is affected, a radiated or a reflex- 
headache is produced; so far as the sympathetic fibers are affected a 
vasomotor reflex is produced. This is equally true where there are 
inflammatory conditions, as ethmoiditis. It matters little whether the 
pressure is from within the ethmoid cells and turbinal or from without 
these structures. The important point is that the same branches of 
these nerves are pressed upon, and, therefore, the same kind of dis- 
turbances should be expected to follow. 

The asthenopic disturbance is probably due to irritation of the sym- 
pathetic fibers in this particular class of cases. That it is such in all 
cases is also probable. It could be inferred from other facts, e. g., when 
treatment addressed to the uterus, the bladder, or the stomach has given 
relief to the asthenopic symptoms. 

In the light of the foregoing views expressed by Hoople, asthenopia or 
disturbed function of the ciliary and external ocular muscles is usually 
due to intranasal pressure and irritation in the middle turbinal and 
ethmoidal regions, rather than to toxemia from infection of the sinuses. 
The speedy relief of the asthenopia following the divulsion or the removal 
of the offending middle turbinal seems to prove this view rather than the 
view referring the disturbance to toxemia. 

In the cases referred to by Hoople the headaches were of the ocular 
rather than the sinus type, as they were induced, or aggravated, by the 
use of the eyes, and were relieved upon retiring for the night. Sinus 
headache is not always aggravated by using the eyes, and is often most 
pronounced upon awakening. 



CHAPTEK III 

THE OFFICE EQUIPMENT 

In the equipment of an office the chief point to be considered is facility 
in treating patients. The treatment and consultation rooms should 
be equipped for work rather than for entertainment. Everything for 
facility and thoroughness; nothing for show. "Bluff" is a confession 
of unfitness. Thorough knowledge and frankness of statement will 
inspire confidence and give an impression of mastery as no amount 
of "bluffing" will do. 

The essential furnishings of the consultation room and treatment 
room should consist of the following : 

(a) Treatment and operating chair, (b) A revolving stool for the 
surgeon, (c) A treatment table or cabinet, (d) A fountain cuspidor, (e) 
A linen cupboard, (j) A writing desk, (g) A sterilizer. (K) A revolving 
desk chair, (i) Two small chairs, (j) An adjustable bracket for the 
examination lamp, (k) A selection of instruments and apparatus for 
examinations, treatments, and operations. 

The Treatment and Operating Chair.— This should be a revolving 
chair, as suggested by Dr. Robert Levy, as it is desirable to turn the 
patient from side to side in treating his ears, and for other reasons as well. 
The bottom should be on a central screw pin, so that it can be adjusted 
to different heights for children and adults. The back should be so 
constructed that it can be lowered to a horizontal position in case of 
faintness and when it is desirable to operate with the patient in a prone 
position. An adjustable head-rest should be attached to the back of 
the chair (Figs. 4 and 5). An ordinary chair may, of course, be used, 
but in the case of faintness, etc., the work is greatly facilitated and the 
comfort of the patient assured if the chair is of 'the adjustable type 
described. 

The Treatment Table or Cabinet.— If an assistant is employed it is 
preferable to have the instruments in a separate cabinet in an adjoining 
sterilizing room or corner. The treatment cabinet may then consist of 
a metal enamelled frame with a plate-glass top, or it may be a double- 
decked table, with top and shelves about one foot apart. These tops 
afford ample room for the distribution of bottles containing remedies 
for topical applications and for the instruments of examination and 
operation. 

The treatment table, or cabinet (Fig. 6), is an important piece of 
furniture. Its selection should depend largely upon whether the sur- 
geon has an assistant to wait upon him. If he has, the cabinet need not 
be constructed to contain all instruments, as the assistant will bring 
(36) 



THE OFFICE EQUIPMENT 



37 



such as are necessary for each case. If he does not have an assistant, 
it is convenient to have the instruments in the cabinet within reach. 

The Hot-water Basin. — A most excellent addition to the table is a 
basin, set in the centre of the upper glass top, with running hot water for 
the purpose of rinsing instruments during the course of treatments. If 
preferred, the hot-water basin may be attached to a special wall bracket 
(Fig. 7), as it is only intended as a convenience. It is also useful in 
cleansing and warming the laryngeal mirror during throat examinations. 



Fig. 4 



Fig. 5 





Operating chairs. 



No matter how sterile the tongue depressor may be when first used, its 
introduction into the mouth the second or third time without cleansing 
is, to say the least, disgusting to the patient. 

A basin of running hot water is, therefore, an invaluable and, I might 
add, an indispensable adjunct to the office equipment. It is not, however, 
indispensable in so far as the safety of the patient is concerned, as only 
his own secretions come in contact with the instrument used. If the 
fundamental principles of common cleanliness are to be recognized it is a 



38 



THE NOSE AND ACCESSORY SINUSES 



valuable and necessary office fixture. It is not a question of whether 
it pays, but rather one of common decency, and that always pays. 



Fig. 6 




Pynchon's medicine and instrument cabinet. 
Fig. 7 Fig. 8 





Clark's hot-water basin. 



Clark's fountain cuspidor. 



A bowl of antiseptic solution is not a substitute for running hot water 
unless the bowl is refilled for each rinsing. The solution would otherwise 



THE OFFICE EQUIPMENT 



39 



Fig. 9 



soon become thick with secretions and detritus, and the introduction of 
an instrument into it for rinsing purposes would be even more disgusting 
than no rinsing at all. 

The Examination Lamp. — The examination lamp may be a kerosene, 
gas, or an electric lamp; the latter is preferable, because it gives off less 
heat and requires less attention. The lamp may or may not have a hood 
with a focussing lens, as the surgeon may 
elect. Personally, I prefer an electric lamp 
of 50 candle-power (Fig. 9). This should 
have a ground-glass surface, except a circular 
area on one side, where the glass should be 
clear. 

It affords plenty of light, is simple, throws 
out little heat, and is inexpensive. 

A wall bracket to support the lamp is an 
important item, inasmuch as it is constantly 
used. It should, therefore, be well con- 
structed and accommodate itself to the vary- 
ing conditions under which it is used. That 
is, it should be so constructed that the lamp 
can be raised and lowered and turned from 
side to side with the least trouble to the 
operator. It should be so well made that 
it will never get out of order, a state or con- 
dition into which many wall-lamp brackets A 50 candle . power electric lamp 
are likely to fall. That shown in Fig. 10 with a rotating socket. 




Fig. 10 




Wall-lamp bracket. 



has proved quite satisfactory in nearly every respect. A Kierstein 
head lamp (Fig. 11) is preferred by some operators. 

Compressed-air Apparatus. — The compressed-air apparatus may 
be one of three types: (a) A hand bulb; (b) a tank pumped by hand or In- 
some automatic device, as a water pump; or (c) a system of compressed 



40 THE NOSE AND ACCESSORY SINUSES 

air supplied throughout the building by means of pipes from a central 
compressed-air tank. The latter is preferable when it can be obtained, 
as it requires no attention whatever. A compressed-air tank in the 
office automaticaly supplied by means of a hydraulic pump is the 
next most preferable arrangement. A hand pump is inconvenient 
and necessitates considerable labor. The hand bulb is suitable when 
eight pounds or less of pressure are required. 

An Accessory Regulating Air Tank. — An accessory regulating air 
tank is a very convenient and valuable addition to the compressed-air 
system, as it enables the surgeon to use the amount of pressure required 
for various purposes. The nasal mucous membrane, for example, will 
not tolerate a higher pressure than ten pounds with the De Vilbiss spray 
tube, whereas the pharynx will tolerate from twenty to forty pounds' 
pressure. A nebulizer requires a higher pressure than the spray tube, 
and in inflation of the Eustachian tube and middle ear the pressure 

Fig. 11 




Kierstein lamp and head bracket. 

required varies from eight to twenty pounds, according to the degree 
of obstruction present. Hence, a regulating air tank is a convenient 
if not a necessary apparatus. The tank should be connected with the 
main reservoir and the compressed air turned on until the gauge indi- 
cates the required pressure, say ten pounds. If at another time in the 
treatment but two pounds' pressure is needed the escape valve may be 
opened until the gauge indicates two pounds. There are many other 
ways in which such a regulating air tank may be used to advantage. 
The gauge regulators on the market are not nearly so satisfactory as the 
Pynchon and Hubbard regulating tanks, and are not recommended. 

Massage Apparatus.— Ear Drum.— Pneumomassage, or the massage 
of the ear drum by the alternate rarefaction and condensation of the air 
in the external auditory meatus, is accomplished by means of a hand 
pump, as first devised by Delstanche, of Brussels (Fig. 12), or it may be 
operated by an electric motor, as first devised by Chevalier Jackson, of 



THE OFFICE EQUIPMENT 



41 



Pittsburg, and later, in 1S93, improved by Pynchon (Fig. 13). The 
pneumomassage of the ear drum is recommended in deafness and ear 

Fig. 12 




Delstanche's rarefactor and artificial leech. 
Ftg. 13 




The Victor electrocautery with Pynchon's pneumomassage pump. 

noises of catarrhal origin, though its value has been greatly exaggerated. 
Delstanche was of such high repute that he was awarded the Lenval prize 



42 THE NOSE AND ACCESSORY SINUSES 

for having designed the best instrument for relief of deafness, hence 
the procedure was adopted by aurists all over the world. Subsequent 
experience with it and its modifications has not justified the high expecta- 
tions with which it was received. Pneumomassage has a place in aural 
practice, however, as by it the mucous membrane is brought into a 
more active and resistant state, and the labyrinth is also stimulated 
to greater functional activity. In a limited number of cases the ossicles 
of the ear are rendered more mobile and transmit sound better after 
its application. Tinnitus is also occasionally relieved by it. Such 
cases require rare skill and knowledge to determine what is best to do 
for them. Routine inflation and pneumomassage are almost without 
result except in a few cases. Accurate diagnosis is of first importance; 
then the treatment should be very carefully and intelligently prescribed. 
Few cases of deafness and tinnitus are relieved by pneumomassage. 

Then, too, the massage apparatus should be regulated to suit each 
case. The length of the piston stroke, the frequency of the vibrations, 
and the length of time the massage should be used are questions to be 
settled according to the peculiarities of each case and the experience 
and judgment of the surgeon. Massage per se is of no value as a thera- 
peutic agent. It is only when it is used with "brains" that it becomes 
of value. Surgeons who are uninformed and inexperienced are often 
tempted to furnish their offices with formidable-looking mechanical 
devices, with the belief that they are- thus preparing themselves to ade- 
quately cope with" disease. If they are intelligent observers, they soon 
learn that the "man behind the gun" is the first requisite for the attain- 
ment of success. 

I have, however, found the hand apparatus of Delstanche of the 
greatest value as a diagnostic and therapeutic agent. With it the ear 
drum may be observed under compression and rarefaction, and points 
of adhesion and of atrophy are clearly demonstrated. When the air is 
rarefied in the meatus, the points of adhesion being fixed, the remainder 
of the membrane bulges outward, leaving no doubt as to the condition 
of the middle ear. If there is an atrophic area in the ear drum it bulges 
like a blister beyond the other parts of the membrane. If the otoscopic 
portion of the apparatus is provided with a magnifying lens the texture 
of the ear drum may be clearly demonstrated. 

Aside from the diagnostic value of the Delstanche apparatus, its greatest 
usefulness is in the treatment of the exudative forms of middle-ear 
catarrh. It is in the protracted course of these cases that the adhesive 
processes form. The viscid exudate agglutinates the ear drum to the 
inner tympanic wall, becomes organized, and thus permanently fixes it to 
the inner wall of the middle-ear cavity. The timely and intelligent use 
of the Delstanche rarefactor, or other pneumomassage apparatus, may 
prevent permanent adhesions. The apparatus should in the beginning 
be used daily with a slow, long stroke of the piston. After the inflam- 
matory process has abated and the exudate is less viscid and less pro- 
fuse the treatment may be gradually reduced in frequency and finally 
abandoned. The length of the stroke (force of the suction) should 



THE OFFICE EQUIPMENT 43 

be gradually diminished, as a too long-continued stretching of the 
membrana tvmpani will render it abnormally lax from pressure (suction) 
atrophy. 

Another device for the massage of the ear drum consists of a glass 
tube partially filled with metallic mercury (Fig. 14). The open end of 
the tube is shaped to fit the external meatus, and when not in use is 
closed with a rubber cork. Its application is simple, the uncorked end 
being placed firmly in the external meatus, and the patient instructed to 
move the head from side to side, allowing the mercury to drop against the 
ear drum. This procedure is repeated several times at each daily seance. 
According to Dr. Joseph C. Beck, its originator, the rationale of its use 
consists in the impact of the mercury against the malleus and ear drum, 
the force being transmitted to the entire ossicular chain and to the laby- 
rinth. This stimulates the functional activity of these structures and 
improves the condition present. Dr. Beck has found its chief useful- 
ness in the relief of the tinnitus rather than the deafness, a fact which 
to my mind is significant. That is, the mechanical shocks thus applied 
to the membrana tvmpani and transmitted to the labyrinth affect the 
circulation of the labyrinth, improve the nutrition, and increase the local 
leukocytosis. Dr. Beck has also noted that the improvement was usually 
transient, lasting only a few days or weeks after discontinuing the treat- 
ment. 

Fig. 14 



Beck's mercury massage. 

The Electrocautery. — So much has been said within recent years 
about the use, or rather the uselessness, of the electrocautery (Fig. 13) 
that I feel impelled to defend it. It is still a very useful apparatus, 
and an office is incomplete without it. It is true that it has been tco 
frequently, indiscriminately, and unintelligently used, but it still fills 
a place of great usefulness in the armamentarium of the specialist. 
Its usefulness in turgescent rhinitis has been greatly abridged by the 
improved methods of operating upon the nasal septum (notably the sub- 
mucous resection), but even in this condition it still affords a means of 
temporarily overcoming the excessive swelling of the inferior turbinated 
bodies. It also affords a valuable means of treating chronic granular 
pharyngitis with lymphoid enlargements along the lateral and posterior 
walls of the pharynx. Still other uses could be described, but as they 
are mentioned in connection with the respective diseases, the two cita- 
tions are sufficient to show that the electrocautery apparatus is not an 
obsolete instrument. 

Spray Tubes. — The spray tubes and the medicated fluids used in 
them have also come under the ban as therapeutic agents. There was 
a time when the rhinologist and laryngologist was called the "spray 
specialist," more derisively a "squirt-gun doctor." Whatever grounds 



44 



THE NOSE AND ACCESSORY SINUSES 



there may have been for these characterizations it is certain that they 
do not apply to the specialist of the present time. Nearly all special 
surgeons now recognize the futility of attempting to cure diseases of the 
nose and throat by means of medicated water and oil. The etiology of 
the catarrhal and suppurative inflammations of the nose and throat is 
better understood, and the ideas concerning their treatment have under- 
gone corresponding changes. It is being more and more recognized that 
mucous-lined cavities are subject to catarrhal and infective inflammation 
somewhat in proportion to the degree of obstruction to their drainage 
and ventilation. This one factor is probably the most significant etiolog- 
ical factor emphasized in recent years. Goodale and Jonathan Wright 
emphasize it in reference to the crypts of the tonsil. Heath has recently 
emphasized the same truth in reference to the mastoid antrum and the 
middle ear. (See Meatomastoid Operation; also the Clinical Anatomy 
of the Nose, and the Inflammatory Diseases of the Nose and Accessory 
Sinuses.) 

Fig. 15 




De Vilbiss' atomizer and nebulizer. 



In view of this more modern conception of the etiology of the inflam- 
matory diseases of the ear, nose, and throat, surgical procedures have 
largely replaced the topical and caustic applications once in popular 
favor. The spray tube, or atomizer, occupies a less conspicuous place 
than it did a few years ago (Fig. 15). An array of fifty or a hundred 
spray bottles, each with a different medicated or perfumed solution, 
is no longer a necessary part of an office outfit; indeed, such an array 
of spray formula? is in some ways a confession of an antique, if not alto- 
gether obsolete, conception of medical practice. Spray tubes are, never- 
theless, necessary adjuncts to the office outfit, as they should be used 
to cleanse the nasal and throat cavities before operating and treating 
acute and chronic inflammations. 

George F. Hawley's spray tube (Fig. 16) is the best cleanser, as it 
throws out a coarse spray in every direction and softens and dislodges 



THE OFFICE EQUIPMENT 



45 



the tenacious and dried secretions. The straight tip may be inserted 
into the sphenoidal sinus after the middle turbinate has been removed, 
and the secretions thoroughly washed out. The apparatus as a whole 
is an excellent substitute for other methods of irrigating the nose. The 
straight tip may be bent to conform to the requirements for reaching 
the frontonasal duct and maxillary sinus. Postnasal and laryngeal 
tips make it a universal instrument for irrigating the upper respiratory 
passages on account of the improved methods of topical and surgical 
treatment now in vogue. 

Fig. 16 





Hawley's spray tube. 



The Mechanical Vibrator. — Some years ago the mechanical vibrator 
was mentioned as acting favorably upon tinnitus and deafness, but its 
more general use by English and American otologists has demonstrated 
its comparative uselessness for these purposes. At that time it was 
stated that when applied over the spinal column it seemed to act favor- 
ably upon the ear. I have tried it faithfully for this purpose, with 
no appreciable effect. Its chief field of usefulness is in reducing the 
swelling and sensitiveness of the glands of the neck and the headache 
accompanying the various sinus affections. But even these conditions 
are better and more pleasantly ameliorated by the leukodescent lamp. 
The vibratory or mechanical massage increases the lymphatic flow, 
improves the nutrition, and increases local leukocytosis. Hence, it 
relieves pain and tenderness, and reduces the activity of an inflammatory 
process, provided it can be applied to the parts. In this respect it acts 
upon the principle of Bier's constriction and negative pressure treatment 
and the leukodescent-light treatment; that is, it increases the local leuko- 
cytosis, improves the local nutrition, and thus diminishes the infectious 
process. 

Negative Pressure Apparatus. — This apparatus consists of a device 
whereby the air pressure is reduced in the upper air passages, notably the 
nose and accessory sinuses (Figs. 17 and 18). The negative air pressure 
within the nose and accessory sinuses facilitates the discharge of the 



46 THE NOSE AND ACCESSORY SINUSES 

secretions and purulent accumulations, increases the local nutrition and 
leukocytosis, and acts favorably upon the inflammatory process. Its chief 
field of usefulness seems to be in the treatment of the subacute inflamma- 
tions of the sinuses, though it exerts a favorable influence upon chronic 
sinuitis. 

Fig. 17 




Brawley's vacuum aspirator. 



Fig. 18 



Fig. 19 




Pynchon's modification of Dabney's vacuum aspirator. 



The leukodescent therapeutic lamp. 



The Leukodescent Lamp.— The leukodescent lamp is a single in- 
candescent globe of 500 candle-power (Fig. 19), around which is placed a 
reflector eighteen inches in diameter. The reflector focuses the rays ot 
light, thus increasing their penetrating power. The therapeutic properties 



THE OFFICE EQUIPMENT 



47 



of the leukodescent light are in the heat and chemical rays. The leuko- 
deseent light is rich in blue-violet rays, in addition to the light and heat 
rays. The blue-violet are very active chemical rays and increase the 
tissue metabolism and the leukocytosis, thus providing for the destruction 
of the pathogenic bacteria. 

Clinically, I have found the leukodescent light of value in infectious 
and inflammatory processes. For instance, I have seen cases of chronic 
maxillary empyema with granulations cease discharging under its 
influence. The pain, tenderness, and swelling likewise disappeared. 
In no case, however, have I seen a cure by this mode of treatment. In 
acute sinuitis I have seen marked and rapid improvement follow its 
use. Infection of the mastoid wound rapidly improves under its use 
three times daily. Cervical adenitis usually responds readily to the 
rays. Pain of almost any origin is relieved and in many cases stopped 
by it. The pain of sarcoma is almost invariably checked. It seems 
to exert a slight control over an oozing postoperative hemorrhage. Its 
power to increase tissue metabolism and local leukocytosis reduces 

Fig. 20 




Pynchon's sterilizer and instrument dryer. 

the bacterial activity. The latter is probably due more to the increased 
leukocytosis than to the bactericidal property of the rays. While they are 
bactericidal when applied continuously for ten minutes at a distance 
of thirteen inches in the laboratory, they are probably not bactericidal 
at eighteen inches for a few moments at short intervals in their clinical 
application. The rays are too hot to be tolerated constantly at close 
range, hence the effects produced in laboratory experiments cannot be 
duplicated in actual practice. 

Lamps of less candle-power are correspondingly poor in the blue- 
violet rays, the 50 candle-power lamp having scarcely a trace of them. 
It has been shown that ten 50 candle-power lamps grouped have iden- 
tically the same quality of rays as a single 50 candle-power lamp, and 
that the rays are in no way similar to those given off by a 500 candle- 
power lamp. A single 500 candle-power lamp should be chosen, as 
a lamp of less capacity is not sufficiently rich in the chemical rays to 
produce the best results. 

A Sterilizer for Instruments and Gauze. — An office outfit is not com- 
plete without a sterilizer of some kind. All instruments should be boiled 



48 THE NOSE AXD ACCESSORY SINUSES 

in a 2 per cent, solution of soda? biboras for at least twenty minutes 
before they are used, for either examinations, treatments, or surgical 
operations. The instruments may be boiled in a porcelain-lined bucket 
or pan, or in a specially designed sterilizer, as shown in Fig. 20. The 
apparatus shown in the illustration is provided with a drying chamber 
in addition to the boiling tray, and is recommended on this account. 
Instruments are often damaged or altogether ruined because they are 
not dried after being sterilized. With this sterilizer they may be boiled 
and dried after an operation. 

Topical Applications. — Topical remedies which should have place 
upon the treatment table are numerous, though individual preference 
may greatly modify their number and character. I shall only refer to 
those which have proved satisfactory in my practice. 

Nitrate of Silver . — The following solutions of the nitrate of silver should 
be kept on the treatment table in blue-glass bottles, or in a cabinet within 
convenient reach of the surgeon or his assistant: 

1$. — Argenti nitratis gr. x 

Aquae des 3j — M. 

This is approximately a 2 per cent, solution of the silver salt, and is 
useful when a mild but positive astringent action is required, as in 
simple subacute catarrhal inflammation of the upper respiratory tract. 
It may be applied with a spray tube, the essential parts of which are made 
of hard rubber and aluminum, or of glass. Other metals are acted 
upon by the silver salt, and are not suitable for the silver solutions on 
this account. The silver solution may also be appiled with a cotton- 
wound applicator. A camel's-hair brush is not recommended, on ac- 
count of the difficulty of keeping it sterile. 

1^. — Argenti nitratis gr. xx 

Aquae des. §j — M. 

This solution is approximately 4 per cent, in strength, and may be 
used as No. 1 when a more positive astringent and antiseptic action is 
required. 

1$. — Argenti nitratis gr. xl 

Aquse des gj — M. 

This solution is approximately 8 per cent, in strength, and is useful 
in the more chronic catarrhal inflammations of the upper respiratory 
tract. Solutions of greater strength than this are rarely indicated in 
chronic inflammations of the mucous membrane except when a caustic 
action is required. Greater strengths are apt to cause irritation and an 
aggravation of the local chronic inflammation. 

In the very acute inflammations a much higher percentage of silver 
may be used. 

ty. — Argenti nitratis 3j 

Aquae des q. s. ad §j— M. 

This is a 12J per cent, solution, and is a valuable local remedy in acute 
lacunar inflammation of the tonsils. The more acute the attack and 
the more edematous the tissue the stronger the silver solution should be. 



THE OFFICE EQUIPMENT 49 

1$. — Argenti nitratis 3 i j 

Aquae des q. s. ad 5J — M. 

This is a 25 per cent, solution, and is useful as a local application in 
acute infectious inflammations of the fauces. It is especially useful in 
acute lacunar tonsillitis, one application in the primary stage often being 
sufficient to abort the inflammatory process. 

1$. — Argenti nitratis gr. ccccxxxij 

Aqua? des q. s. ad 5j 

This is a 90 per cent, solution, and is useful in acute lacunar tonsillitis 
in the most virulent and acute stage. It should only be applied when 
the inflammation is very recent and aggravated in type. The tissues 
should be succulent and highly inflamed. In such a case it is a specific 
remedy. I have never seen a case corresponding to the above descrip- 
tion in which the second application of the remedy was necessary. Its 
use in this strength is not painful, but, on the contrary, relief immedi- 
ately follows. 

If this strength of solution were applied to a subacute inflammation 
the chemical trauma would probably aggravate the existing inflammatory 
process rather than relieve it. A solution of silver salt of this strength 
coagulates the mucous secretions and blanches the surface of the inflamed 
mucous membrane. It is also a powerful germicide. The inflammatory 
infiltration of the tissue is checked and the vitality of the infective bac- 
teria is greatly impaired. 

Caution should be observed in using silver nitrate. The salt in any 
strength has a marked irritating effect on the intrinsic muscles of the 
larynx. To avoid this accident the cotton- wound applicator should be 
freed of the excess of the solution by squeezing it with a liberal wad of 
cotton. When this is done the inflamed area should be lightly brushed 
with it. 

The following rules are valuable: (a) The milder the inflammation 
the milder the solution (b) The more intense the inflammation the 
stronger the solution. 

Guaiacol Solutions. — Solutions of guaiacol in olive oil are useful local 
remedies in acute inflammation of the fauces and pharynx. 

The strengths recommended are 10, 25, and 50 per cent, of guaiacol 
in pure olive oil. The more severe the inflammation the stronger the 
solution required. 

While guaiacol is not as efficient a remedy in acute tonsillitis as the 
stronger solution of silver, it is nevertheless very positive in its action, 
many cases requiring but a few applications to check the inflammatory 
process. It produces a pungent, hot sensation which lasts for about 
thirty seconds. 

Compound Tincture of Benzoin. — The compound tincture of benzoin 
is a valuable local remedy in the throat when a mild but positive astrin- 
gent and antiseptic remedy is indicated. It may be used in chronic 
granular pharyngitis during the mild exacerbations of the disease with 
good effect. 
4 



50 THE NOSE AND ACCESSORY SINUSES 

Its chief value is as an adjunct in dressing the nasal accessory cavities. 
The gauze should be moistened in the solution, the excess removed by 
squeezing, and packed in the nasal cavity. It prevents decomposition 
and stimulates healthy granulations. A plain gauze dressing in the 
nasal chambers, if allowed to remain more than twenty-four hours, 
often takes on a very offensive odor. If the gauze is moistened with 
the compound tincture of benzoin, it may remain in the nose seventy- 
two hours without acquiring an offensive odor. 

A foul-smelling chronic otorrhea may be rendered sweet by mopping 
the cavity dry and applying a dressing of gauze moistened with the 
compound tincture of benzoin. 

Subnitrate of Bismuth Powder. — This powder may be used with gauze 
dressings as a substitute for the compound tincture of benzoin. It also 
prevents decomposition, though not over so extended a period. 

It may also be insufflated (Fig. 21) into the nose after an intranasal 
operation, where it forms a coating which acts as a mechanical and a 
chemical protection to the underlying tissue. 

Fig. 21 




SECTION SHOWING POWDER SCOQK 

Powder insufflator. 



Ichthyol Solutions. — Ichthyol in aqueous and glycerin solutions may 
be used as a topical application in the nasal chambers where there is 
a foul or ozenic secretion. The nose should be packed with cotton or 
gauze saturated with the solution. Personally, I prefer to use a cork- 
screw applicator wound with cotton and dipped in the ichthyol solution. 
This is then introduced into the nasal cavity and the applicator removed 
with a reverse screw motion, leaving the ichthyol pad in the nose. This 
should be left in place for from ten to thirty minutes, according to the 
degree of infection and tumefaction of the tissue. If the secretions are 
profuse and dried in the nasal cavities, the aqueous solution should be 
used; if there is a state of sepsis and local tumefaction of the tissues, the 
glycerin solution should be used on account of its hygroscopic action. 

Iodine Solutions. — Iodine in a glycerin menstruum is a valuable 
remedy in chronic granular pharyngitis, and in those cases of middle- 
ear catarrh associated with granular pharyngitis or atrophic rhinitis. 

The following formulae may be used in such cases : 

, fy— Tr. iodini tlfcdviij 

Glyeerini . . q. s. ad 5j — M. 

]$. — Iodoformi o gr _ j 



Potas. iodidi 



gr. x-xx 



Morphia sulphatis gr> j 

Glyeerini gj — jy{. 



THE OFFICE EQUIPMENT 51 

1$. — Iodini gr. v-xx 

Potas. iodidi gr. x-xxx 

01. gaultheria Vf[v 

Glycerirji 5j — M. 

1$. — Tr. iodidi. 
Tr. ferri chl., 
Glycerini aa q. s. 5J — M. 

The fourth formula is very astringent, and is used to promote even 
healing by granulation after tonsillectomy in adults. It is also of great 
value in the subacute type of granular pharyngitis. 

Carbolic Acid. — Carbolic acid may be used in any strength from 10 
to 95 per cent, aqueous or glycerin solution. 

1$. — Carbolic acid gr. xx 

Glycerin gj — M. 

This is approximately a 4 per cent, solution, and may be used in sub- 
acute dry dermatitis of the external auditory meatus and in subacute 
otitis media. 

1$. — Carbolic acid 5J 

Glycerin q. s. ad gj — M. 

This is a 12 per cent, solution, and may be used in acute otitis media. 
It should be dropped into the meatus two or three times daily and a 
cotton plug introduced to prevent its escape (A. H. Andrews). It is 
claimed that if dropped into the meatus in the initial stage of acute 
suppurative otitis media it aborts the further progress of the inflammation 
in nearly every instance. On the other hand it is claimed that its frequent 
use causes a fibrosis and thickening of the ear drum, and thus causes 
permanent diminution of hearing. It may be said, however, that its 
frequent use is not often required to abort an attack of acute otitis media. 

3$. — Carbolic acid gr. ccclvj 

Aquae des TT]xxiv — M. 

This is a 95 per cent, solution of carbolic acid, and may be used when 
a superficial caustic effect is desired, as in infective granulomata of the 
middle ear and mastoid, either before or after operation. I have occa- 
sionally used it in cases of old, foul-smelling otorrhea to diminish the 
odor and to stimulate healthy granulation. (See Chemical Caustics.) 

Alcohol. — Alcohol is also a valuable remedy for topical applications. 
I know T of no better ingredient for a gargle than alcohol. It is astrin- 
gent and antiseptic, and, when properly diluted, is grateful to an inflamed 
surface. 

fy— Alcohol, 

Cinnamon water . aa 5i.i 

Formaldehyde ffUJ 

Glycerin 5v 

Aquas des q. s. ad gvii.i M. 



The above formula is a good gargle in acute tonsillar and pharyngeal 
inflammations and in the soreness following the removal of the tonsils. 
In very young children it may be used in a more diluted form. 



52 THE NOSE AND ACCESSORY SINUSES 

In chronic otorrhea alcohol may be used in the following dilutions and 
mixtures : 

fy— Alcohol Ipart 

Aquae des. 2 parts— M. 

1$.— Alcohol Ipart 

Aquse des. 1 part— M. 

1^.— Alcohol . . . . • 2 parts 

Aqua? des. 1 part— M. 

1$.— Alcohol 3 parts 

Aquse des. ................ 1 part — M. 

1^.— Alcohol 95 per cent. 

The alcohol dilutions given above are used principally in the treat- 
ment of chronic suppurative otitis media. 

They constitute the so-called "alcohol treatment" of this disease: 
The meatus is first filled with the weakest solution, then mopped out, 
and each solution applied in series until the patient tolerates the 95 per 
cent, solution. If the strongest solution is applied at once it causes 
considerable pain and irritation, whereas if the strength is gradually 
increased unpleasant results are avoided. 

Alcohol is a positive astringent and antiseptic remedy of considerable 
value. 

I^. — Alcohol (95 per cent.) ............. §j 

Boric acid gr. xx — M. 

1$. — Alcohol (95 per cent.) 5J 

Iodoform gr. v — M. 

The addition of boric acid and iodoform is supposed to give the local 
antiseptic effect of these drugs. If an excess of either drug is added, 
and the solution is agitated just before the instillation of the solution, a 
precipitate of the partially suspended drug is deposited on the diseased 
mucous membrane. 

These solutions should be used after having applied the weaker alco- 
holic solutions. 

Ointments. — Various drugs may be prepared with an oily menstruum, 
preferably lanolin, as it has greater affinity for the mucous membrane 
than vaseline. Pure olive oil may also be used as a menstruum. The 
following mixtures are recommended: 



3$. — Zinc oxide 
Lanolin 



Kr 


xlviij 


3.i 


— M. 


gr. 


xlvij 


gr. 


J 


gr. 


tU 



ly. — Zinc oxide 

Morph. sulph 

Atropine 

Lanolin q. s. ad 5j— M. 

The first formula is soothing to an inflamed surface, and may be 
applied in those cases in which there is an irritating mucous or sero- 
mucous discharge in catarrhal sinuitis. It is also of use in the massage 



THE OFFICE EQUIPMENT 53 

of the nasal mucous membrane in rhinitis with collapse, and in tumes- 
cence of the "swell bodies." For this purpose a delicate silver applicator 
should be wound with a small wisp of cotton and dipped into the oint- 
ment. The nasal mucous membrane should then be gently massaged 
with the ointment, the probe being lightly held between the thumb and 
forefinger. The wrist movement, or the combined wrist and forefinger 
movement, should be used in performing the massage. The applicator 
should he held so lightly that if the cotton-wound applicator should 
strike a turbinated body or other obstruction the probe will slip through 
the fingers and do no damage. 

The sensitiveness of the mucous membrane may be quickly removed 
by the above procedure. 

The second mixture is of value when the nasal mucous membrane 
is sensitive and when there is an acute exacerbation of the inflammation. 
The morphine and atropine relieve the sensitiveness and reduce the con- 
gestion. 

1$. — Ichthyol ... , gr. xlviii 

Lanolin . gj — M. 

The ichthyol ointment may be used in those cases where the secretions 
are dried in the nasal cavities to stimulate the glandular functions. It 
may be applied by massage, as described above. 

Chemical Caustics. — Chemical caustics are largely replaced by the 
electrocautery, though there are instances in which the chemical caustics 
are preferable. The following are recommended: 

Carbolic Acid (95 per cent.). — Where a superficial and diffused cauteri- 
zation is desired, as in an unhealthy granulating surface, carbolic acid 
is an ideal caustic agent. It does not penetrate deeply, nor does it pro- 
duce pain. It is also of value in cases of old suppuration of the ear, in 
which there is a foul odor and exuberant granulations. The ear should 
first be thoroughly freed from secretions with a cotton-wound probe and 
the carbolic acid applied afterward. After one minute has elapsed 
alcohol should be dropped into the meatus to check the action of the 
carbolic acid and to prevent its action upon the skin of the meatus and 
auricle during its removal. The carbolic acid should be dropped into 
the middle ear with a medicine dropper, care being exercised to avoid 
contact with the cutaneous surface. 

Carbolic acid may also be used in the pharynx when a diffused 
superficial caustic action is desired, as in a mild case of granular 
pharyngitis, though in these cases it is usually preferable to puncture 
the follicles or nodules scattered over the pharyngeal wall with the 
galvanocautery. 

Chromic Acid. — Chromic acid has long been a favorite chemical caustic 
in the nose, throat, and ear, though it has been largely replaced by the 
galvanocautery. A few crystals are engaged upon the end of a probe 
and held over an alcohol or gas blaze to drive off the water of crystal- 
lization, but not long enough to reduce them to an ash or cinder. The 
bead of acid thus formed is drawn across the area to be cauterized, 



54 THE NOSE AXD ACCESSORY SINUSES 

where it rapidly abstracts the water from the tissue and thus destroys 
or cauterizes its superficial layers. 

It may be used in turgescent rhinitis, follicular pharyngitis (granular 
pharyngitis), and in any other condition requiring cauterization. It is 
not as deep in its penetration as is usually desired in either of these con- 
ditions, hence it is not as reliable as the galvanocautery. 

In order to increase its efficiency, Xorval H. Pierce and Max A. Gold- 
stein have devised instruments for its subcutaneous use. The submucous 
method has not, however, appealed strongly to the profession, as the 
galvanocautery is easily and efficiently applied with equally good or 
even better results. 

It should be remembered that chromic acid is quite irritating to the 
kidnevs, and may cause albuminuria. Its extensive use is, therefore, 
contraindicated in cases already thus affected. 

Technique. — (a) Local cocaine anesthesia, (b) Puncture the mucous 
membrane at the anterior end of the free border of the inferior turbinated 
body, (c) Introduce a probe or other elevator through the puncture 
and tunnel the substance of the mucous membrane, keeping near the 
periosteum, (d) Introduce the Goldstein concealed probe containing 
the bead of chromic acid into the depth of the tunnel, (e) Uncover 
the bead of chromic acid and withdraw it through the tunnel. This 
cauterizes the wall of the tunnel within the mucous membrane. If 
sloughing does not occur the result is very good (Fig. 106) . 

Trichloracetic Acid. — This is a valuable chemical caustic agent and 
is generally used in a 20 per cent, solution. It has been employed 
chiefly in tuberculosis of the larynx, in conjunction with curettage, 
and in hypertrophied and diseased tonsils, after splitting the walls of 
the crypts. 

In laryngeal tuberculosis after the intralaryngeal removal of all the 
tuberculous tissue available by this route the operated area is swabbed 
with a 20 per cent, solution of trichloracetic acid, to destroy any remain- 
ing tuberculous tissue and to seal up the lymphatic openings to prevent 
the spread of the tuberculous process. 

Kaufmann has recommended the free and deep incision of the crypt 
walls of the tonsils, especially of those crypts opening into the supra- 
tonsillar fossa, and applying a 20 per cent, solution of trichloracetic 
acid to the incised surfaces. More than one sitting is usually required 
for this purpose. The object of this procedure is to destroy the diseased 
epithelial lining of the crypts and to cause cicatricial contraction of the 
substance of the tonsil. In this way the tonsil is reduced in size and its 
non-resistant cryptic epithelium is destroyed. 

The acid applications are very painful for a prolonged period of time. 
This, together with the fact that repeated applications are often necessary, 
renders the procedure an undesirable one. The complete removal of 
the tonsil by dissection is a more certain and desirable procedure, as 
both tonsils may be removed at one sitting. 

Nitrate of Mercury. — A 10 per cent, solution of the nitrate of mercury 
may be used to cauterize deep sloughing syphilitic ulcers of the nose and 



THE OFFICE EQUIPMENT 55 

throat, as it excites healthy granulation, and thereby checks the slough- 
ing and syphilitic ozena. 

Antiseptic and Detergent Solutions.— The cleansing of the nose and 
throat with detergent sprays and washes is not as popular a procedure 
now as formerly. Experience has shown that such applications exert 
little curative action on catarrhal and other diseases. They do, however, 
promote temporary increase in the hyperemia and leukocytosis. Such 
solutions also stimulate the constrictor muscle fibers of the "swell bodies" 
of the turbinals, and thus temporarily reduce the turgescence. The 
antiseptic action is probably but slight and of little value. The three 
useful effects of the antiseptic and alkaline nasal washes are therefore 
as follows: (a) Detergent or cleansing effects, (b) Muscular contrac- 
tion of the interlacing fibers of the "swell bodies." (c) Slight promotion 
of the reaction of inflammation. The detergent and stimulating solutions 
recommended are as follows: (1) Seiler's solution. (2) Dobel-Pynchon 
solution. 

(2) 1^.— Powd. sod. bibor. (Squibb), 

Powd. sod. bicarb. (Merck) aa §ij 

Thymoline Oss 

Glycerin (C P.) Oiss 

First mix and triturate the two salts and place them in a one-gallon 
bottle, adding one-half the quantity of glycerin; then let it stand twenty- 
four hours uncorked, with frequent agitations. Next add the remainder 
of the glycerin and continue the agitations for another twenty-four 
hours, with the bottle uncorked as before. Lastly, add the thymoline 
and let the solution stand twenty-four hours. One ounce of this mixture 
should be added to one pint of water, when it is ready for use. 

The solutions may be used with an atomizer, a nasal douche, or a 
syringe. They may also be used as gargles, although the distinctly 
alkaline taste is usually disagreeable to the patient. 

Oily Solutions for Use with a Nebulizer. — Aromatic and antiseptic 
drugs may be added to an oily menstruum and thrown into the respiratory 
tract with a nebulizing device. The action of such mixtures is as an 
emollient or protective agent, and as a stimulant to the mucous glands. 
They also cause contraction of the circular muscle fibers of the arterioles, 
and thereby reduce the congestion. The effects are transient, and afford 
relief without exerting a marked curative effect. 

The following formulae are recommended: 

1. Chlorotone inhalant. 

1$. — Chlorotone gr. xv 

Camphor gr. xxx 

Menthol gr. xxx 

Oil cinnamon ff|v 

Oil petrolatum 15 ij — M. 

2. Acetozone inhalant. 

1$. — Chlorotone ""Ivij 

Acetozone ttlxv 

Oil petrolatum q. s. ad 5ij— M. 



56 THE NOSE AND ACCESSORY SINUSES 

The spray bottles and nebulizing bottles devised by De Vilbiss (Fig. 
15) have proved more satisfactory than any others, as their construction 
is simple and they rarely need repairing or other attention. 

Hawley's spray tube is also a useful device for washing the nasal 
cavities, and is often preferable to the spray tube, as it does not injure 
the epithelium of the nasal mucous membrane. 

The air pressure allowable for spraying the various mucous surfaces 
with De Vilbiss' spray apparatus is as follows: (a) The nasal mucous 
membrane, 4 to 10 pounds. (6) The epipharynx (nasopharynx), 8 to 
20 pounds, (c) The mesopharynx (oropharynx), 10 to 30 pounds. 
(d) The hypopharynx, and larynx, 10 to 30 pounds. The air pressure 
needed for De Vilbiss' nebulizing bottles, 10 to 40 pounds. 

The Pynchon and Hubbard regulating tanks, elsewhere mentioned, 
are of great value in conjunction with the spray and nebulizing tubes. 
Hubbard's regulating tank is. especially recommended, as it has a filter- 
ing device for cleansing the air. It also has an arrangement for heating 
the air. 

Solutions which Produce Ischemia. — Solutions which produce local 
blanching of the mucous membrane are chiefly derived from the supra- 
renal glands of sheep. They produce a powerful contraction of the 
circular muscle fibers of the arteries, which lasts for several minutes. 
They are on this account of diagnostic and therapeutic value. They 
also reduce the amount of primary hemorrhage in operations. 

The following formulae are recommended: 

1$.— Adrenalin chloride 1 to 1000 

1$.— Adrenalin chloride 1 to 2000 

1$. — Adrenalin chloride 1 to 4000 

It is rarely necessary to use the first formula except when there is a 
great deal of secretion and blood to dilute the solution. If applied to a 
clean mucous membrane the second and third formula? are of sufficient 
strength to contract the vessels. Local ischemia is produced for diag- 
nostic purposes in the various forms of rhinitis and in reducing the 
engorgement of the tissues to admit a view of the nasal chambers. 
Adrenalin is also used to check local oozing of blood after operations. 



CHAPTER IV 

THE ETIOLOGY OF DEFORMITIES AND DEVIATIONS OF THE 

SEPTUM NASI 

According to Freeman, Trendelenburg was the first to describe the 
high-arched palate with deformity of the septum nasi, though he did not 
consider it due to lack of development of the maxillary bones. Loewy 
was of the same opinion, though he regarded the Gothic arch as of 
rachitic origin. Zuckerkandl does not accept the rachitic origin, as he 
believes that the lower jaw and not the upper exhibits the rachitic 
influence. However this may be, Freeman reminds us that it is com- 
mon to find the Gothic arch associated with deviated septa. He shows 
that in 302 cases of high-arched palate, 290, or 96 per cent., were asso- 
ciated with deviated septa. 

In studying the Mutter collection, Freeman found many straight septa 
associated with Gothic palates, thus demonstrating that a high arch is 
not necessarily a cause of septal deviation. Indeed, he believes that 
the faulty development of the superior maxillae is a fruitful source of 
deviated septa, especially in dolichocephalic heads. The skulls were 
those of non-Europeans, in whom, as Zuckerkandl has pointed out, the 
deformities of the septum are much more infrequent than in Europeans. 
Mosher has recently called attention to the low position of the floor of 
the antrum of Highmore in skulls with the Gothic palate. 

As the Gothic arch is naturally present in infants, it is easy to under- 
stand that anything which interferes with the development of the skull 
will prevent development of the hard palate and its consequent descent. 
Indeed, in such cases the later development of the alveolar processes 
and the eruption of the teeth will cause the arch to become more peaked. 
As the arch remains high, the septum in its further development must 
bend to make room for its growth. Welcker, in support of this view, 
has shown that those cases in which one maxillary bone descends, the 
other remaining high-arched, convexity of the septum is toward the 
descended maxilla. 

According to Eugene S. Talbot, Morgagni believed that deviated 
septa were due to excessive development of the vomer, while Jarvis 
reported four cases in one family suggesting an hereditary influence. 
Talbot believes that direct hereditarv influence is rare, though there 
may be a family development of the facial skeleton, as shown by 
Sachus' and Welcker's investigations. 

According to Bosworth, the deformities of the septum are usually 
traumatic in origin. He points out that an injury to the nose need not 
be attended by an immediate and obvious deformity, but it may set up 

(57) 



58 THE NOSE AND ACCESSORY SINUSES 

a low-grade inflammation, which in a number of years finally results 
in an obstructive malformation of the septum. This is undoubtedly a 
frequent cause of septal deviations, especially of the anterior cartilaginous 
portion, which is exposed to traumatic influences. That it is a frequent 
cause of deformity of the bony portions (perpendicular plate and the 
vomer) is extremely doubtful, as they are protected from blows by the 
nasal and superior maxillary bones. 

Talbot holds that deviations of the septum are due to the unequal 
development of the adjacent bones, more especially the turbinated 
bodies. Their development in turn depends upon the growth of the 
facial bones, which are modified as the facial angle increases and 
prognathism is lost. The turbinated body being displaced or enlarged 
toward the septum, the septum is crowded to the opposite side. The 
septum is not necessarily pushed over by direct contact of the turbin- 
ated bone, as the respiratory currents of air may cause it to deflect 
during the prepuberty period, when the vomer and perpendicular plate 
are soft and cartilaginous, Talbot believes that the underlying cause of 
septal deformities is a neurosis and degeneracy, in which conditions 
there may be an imballance of development of the various bones of the 
face, total collapse of the outer walls of the nose, associated with an 
arrest of the development of the bones of the face, jaws, dental arch, 
chest, and shoulders. 

Summary.~\. Morgagni thought they were due to excessive develop- 
ment of the vomer; the vomer crowding upward against the descending 
perpendicular plate of the ethmoid caused septal deflection to one side, 
in order to allow of. continued development. 

2. Trendelenburg and Freeman think the chief cause of the deflection 
is in the persistent high or Gothic arch of the hard palate. The vomer 
and the perpendicular plate of the ethmoid are thereby crowded and 
deflected in order to find room for further complete development. 

3. Jarvis believes the chief cause is heredity, and quotes observations 
in support of this theory. 

4. Schaus and Welcker advance the hypothesis of a faulty develop- 
ment of the facial bones, including those of the nose. 

5. Bosworth argues that traumatism is the chief cause of deflections. 

6. Talbot takes the theory of Schaus and Welcker and carries it still 
farther, and says that malformations of the septum are due to neuroses 
or stigmata of degeneracy, which result in irregular development of the 
facial bones. He believes that pigeon chest, adenoids, and deformed 
nasal septa are all due to the same neurotic influences, which arrest 
development in some parts while in others there is an increase in the 
development. 

It is difficult to arrive at a final conclusion concerning these theories, 
as data of almost any kind can be found by one who diligently searches 
for it. It is easy to say there is excessive development of the vomer, and 
to report so many thousands of observations on skulls in which this 
theory is substantiated. Trendelenburg and Freeman have satisfied 
themselves that the Gothic arch is the cause. They say the high arch of 



A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 59 

childhood does not descend as it should, and that the space for the 
vomer and the ethmoid plate is thereby encroached upon and deflection 
results. Talbot and others have studied the so-called high arch and find 
that it rarely exists, also that in some instances there is lack of lateral 
development of the superior maxillae, which gives rise to the Gothic arch, 
or what appears to be an abnormally high arch. Actual measurements 
show them to be no higher than normal. Then, too, Talbot claims that 
many hard palates which are lower than the average are attended by sep- 
tal deformities. He does not deny that traumatism does in some instances 
account for septal deformities, but he does deny that it is the chief cause 
of deviations. He belives that consanguineous marriages predispose to 
the neuroses and that facial deformities result therefrom. He holds 
that the facial bones are transitory and more subject to developmental 
influence than most parts of the skeleton, hence are either arrested or 
overdeveloped in those tainted with the stigmata of degeneracy. 

Dr. Talbot's views present the most rational explanation of this much 
mooted question that has yet been offered. He does not name the over- 
development of a particular bone nor does he claim the failure of the 
palatine arch (roof of the mouth) to descend as being the cause of devia- 
tions of the septum. If these conditions are present he claims they are 
incidental signs of a neurosis or degeneracy. The factor which causes 
excessive development of the vomer or of a Gothic or narrow (not high) 
arched palate causes the deformed septum also. 

In conclusion, I will epitomize the etiology of deformities of the nasal 
septum as follows, in the order of their importance. 

(a) Neuroses or stigmata of degeneracy which causes either an arrest 
or an excessive development of the bones of the face, including the nose; 
one of the expressions of the neurosis being deformed septa (Talbot). 

The theories of Trendelenburg, Freeman, Morgagni, Jarvis, Schaus, 
and Welcker are swallowed up in that of Talbot. The individual theories 
they advance imperfectly convey the true explanation, while Talbot's 
comprehends them all and strikes at the root of the matter. 

(b) Bosworth's traumatic hypothesis is true as to a certain number of 
cases. That it explains a majority or even a large percentage of them 
is doubtful. 

The phraseology used by Talbot may be objectionable, inasmuch as 
it assumes that there are ''stigmata of degeneracy" present in all cases 
not due to traumatism. It would be better, perhaps, to say that deflections 
of the septum are usually due to an incoordination in the development 
of the bones of the face, including those of the nose. 

A CLINICAL CLASSIFICATION OF DEVIATIONS OF THE 
SEPTUM NASI 

Malformation and deviation of the nasal septum may be either develop- 
mental or traumatic in origin. When developmental, any or all portions 
of the septum may be involved, whereas if it is of traumatic origin the 
anterior or cartilaginous portion only is affected, except in rare cases. 



60 THE NOSE AND ACCESSORY SINUSES 

The point of chief clinical interest, however, is in the type and location 
of the deformity rather than in its origin. Even the type and location 
of the deviation have to a considerable degree lost their clinical signifi- 
cance in so far as treatment is concerned, since the perfection of the 
submucous resection of the septum has been accomplished, and so 
many types of septal malformations are found to be amenable to it. 

Cartilaginous Deviations. — When the deformity is limited to the 
cartilaginous portion of the septum it is one of three types, viz. : 

(a) A deflection of the anterior portion generally known as the 
columnar cartilage (Fig. 22). The antero-inferior border of this cartilage 
is turned outward into the vestibule of the nose and obstructs the respira- 
tory passage. This type of deviation is not as serious in its consequences 

as those that obstruct the nasal chamber in 
FiG 29 the region of the middle turbinated body, as 

it only interferes with the ventilation of the 
nasal chamber and accessory sinuses, the 
drainage being unimpaired, except in so far 
as it depends upon the mechanical aid of 
the air current in propelling the secretions 
to the epipharynx. 

(b) An angular deviation in an antero- 
posterior direction is serious in proportion 
to its proximity to the middle turbinal. If 
it is limited to the region of the vestibule 
or the inferior turbinate it is of less clinical 
importance, though its removal is still indi- 
cated. If it obstructs both the middle and 
Deviation of the anterior portion the inferior meatuses its removal is of great- 

of the septal or columnar cartilage ^ i mportance as [ t interferes with both the 
which may be removed through . -T ,... „, ,, 

Hajek's incision by sharp dissection, drainage and ventilation or the nasal cham- 
ber and the accessory sinuses of the nose. 

(c) A perpendicular deviation of the cartilage only interferes with 
the ventilation, without blocking the drainage of the secretions except 
anteriorly, which is inconsiderable. 

Osseous Deviations. — For clinical purposes osseous deviations of 
the septum may be divided into three types : 

(a) A bony ridge or crest along the upper border of the crista nasalis 
and the vomer. The direction of this deformity is backward and upward, 
usually beginning anteriorly about one-half inch from the border of the 
inferior portion of the nasal opening, near the floor of the nose. A 
ridge in this location does not necessarily obstruct the normal inspira- 
tory tract (middle and superior meatuses), nor does it greatly interfere 
with the drainage of the secretions. It does, however, encroach upon 
the inferior turbinated body, and thus causes irritation of this important 
physiological organ and produces a sense of stuffiness of the nose. It 
interferes also to some extent with the posterior drainage of the secretions. 
It also projects to some extent into the respiratory pathway and forms 
a favorable place for the desiccation of the secretions. Crusts are, there- 




A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 61 



fore, generally found upon the anterior extremity of the ridge, and in 
blowing the nose become, detached, tear the epithelium, and give rise 
to epistaxis. "While the ridge may not cause nasal obstruction, it should 
be removed on account of the mechanical irritation of the inferior tur- 
binal and the resulting turgescent and hypertrophic rhinitis. 

(b) The perpendicular plate of the ethmoid bone is often convex or 
cup-shaped and impinges upon the middle turbinate upon the side of 
convexity. This is, perhaps, one of the most serious obstructive lesions 
of the septum, as it obstructs both the drainage and the ventilation of the 
superior meatus, and of the frontal, ethmoidal, and sphenoidal cells. 
Sufficient importance has not been given this type of deviation, hence 
I wish to lay special emphasis upon it. It is this type of deviation, more 
than any other, that gives rise to conditions which result in catarrhal 
and suppurative inflammation of the 

accessory sinuses. In the first place FlG - 23 

the secretions are retained, undergo 
decomposition, and impair the vital- 
ity of the mucous membrane. In- 
fection and inflammatory reaction 
naturally follow. The ostei of the 
sinuses become closed from swell- 
ing of the mucosa, and this still 
further interferes with the drainage. 
Furthermore, the ventilation of the 
superior meatus and of the ob- 
structed sinuses is partially or com- 
pletely lost, and the decomposition 
of the secretions is thereby encour- 
aged. The oxygen of the air within 
the obstructed sinuses is absorbed 
and rarefaction results. 

The blood of the lining mucous 
membrane is attracted to the parts by 
the negative pressure thus created, 
and catarrhal inflammation is promoted. If, in the course of events, 
active pus-producing microbes, such as the streptococci, staphylococci, 
diplococcus pneumoniae, etc., find lodgement there, a suppurative in- 
flammation of the sinuses results. 

It is obvious that this type of deviation is of the greatest importance 
and that the indications for its removal are urgent. 

(c) The combined deviation", including the ridge along the crest of 
the vomer and the convexity of the perpendicular plate of the ethmoid 
bone (Fig. 23), is a very common type of septal deformity, and often 
calls for correction at the hands of a surgeon. The indications for 
operative interference are given under (a) and (6) of Osseous Deviations, 
and need not be further discussed here. The indications are obviously 
more urgent than in either the simple ridge or the convex perpendicular 
plate of the ethmoid, as the ill effects of both deviations are to be reckoned 




A compound deviation of the septum. The 
upper deviation is of the greater clinical im- 
portance, as it blocks the ventilation and 
drainage of the sinuses. 



62 THE NOSE AND ACCESSORY SINUSES 

with. It should be noted that the convexity of the perpendicular plate of 
the ethmoid is usually on the side opposite to the ridge along the crest 
of the vomer, though it may be on the same side. It should also be 
noted that the cartilaginous portion of the septum is deviated with the 
perpendicular plate of the ethmoid, and should, of course, be included 
in the operative field. 

(d) There are still other deformities of the osseous septum, as the 
so-called spurs on the anterior portion, which in reality are composed of 
the crista nasalis and cartilage in combination, though they may be true 
osteomata. 



THE COMPLICATIONS AND SEQUELS OF OBSTRUCTIVE 
MALFORMATIONS OF THE SEPTUM 

A review of the preceding paragraphs naturally leads to the conclusion 
that many of the catarrhal and suppurative inflammations of the nasal 
and accessory sinuses are often due either directly or indirectly to obstruc- 
tive malformations of the septum. 

The whole truth is not expressed in the above statement; nevertheless, 
the deduction is fundamental and should form the working basis in a 
large majority of cases. The etiology of the inflammatory diseases of 
the nose and accessory sinuses is given in Chapter VI. 

The following morbid conditions within the nose and accessory sinuses 
are either directly or indirectly caused, or their course is often largely 
influenced, by a preexisting deviation of the septum: 

1. Acute rhinitis or coryza. 

2. Chronic turgescent rhinitis. 

3. Chronic hypertrophic rhinitis. 

4. Chronic hyperplastic rhinitis. 

5. Acute sinuitis, catarrhal and suppurative. 

6. Chronic sinuitis, catarrhal and suppurative. 

7. Polypoid degeneration of the mucosa of the nose and sinuses. 

8. Atrophic rhinitis. 

It is apparent, therefore, that deviations of the nasal septum should be 
a primary rather than a secondary subject in a systematic text-book on 
diseases of the nose. They are, therefore, herein discussed before taking 
up the consideration of the inflammatory diseases which are so largely 
dependent upon them. 

Indications. — The indications for the correction, or the removal, of 
obstructive deviations of the septum are based upon the following con- 
siderations : 

1. If the deviation of the septum does not interfere with (a) the func- 
tional activity of the "swell bodies" of the inferior turbinates, (b) the 
ventilation of the middle and superior meatuses and the accessory sinuses, 
and (c) the drainage of the same areas it should not be subjected to 
surgical treatment. In other words, deviations of the septum should 
never be corrected simply because they are departures from the median 



THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 03 

line of the nose, but only when they obstruct ventilation and drainage, 
or interfere with the function of the "swell bodies." 

2. The positive indications for the correction of deviated septa are 
present when the septum (a) interferes with the normal functional 
activity of the "swell bodies," or (b) prevents the normal ventilation 
and (c) drainage of the nasal chambers and accessory sinuses. 

If, for instance, a ridge along the crest of the vomer is so prominent 
as to touch the inferior turbinate, or if it extends forward into the vestibule 
far enough to partially obstruct the inspiratory current of air, and thereby 
produces rarefaction of the air posterior to the obstruction, it should be 
removed. The same is true in reference to anterior angular deflections 
of the cartilaginous septum. 

If the deviation is higher up, in the region of the middle turbinate, and 
interferes with the ventilation of the superior meatus and the accessory 
sinuses draining into it, it should be corrected. 

If a septum is tested by the foregoing standards, with a negative 
result, it should not be subjected to surgical correction, no matter how 
great the deviation or deviations may be. 

If, on the contrary, a septum is tested by the foregoing standards, 
with a positive result, it should be corrected by some surgical procedure. 



THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 

The Subjective Symptoms of Obstructed Deviations.— The subjec- 
tive symptoms of nasal obstructions are (a) a sense of fulness, either in the 
lower or upper portion of the nasal chambers, according to the location 
of the deviation. If, for instance, the deviation impinges upon the " swell 
body" of the inferior turbinate there is a sense of stuffiness or fulness in 
the lower portion of the nose; whereas if it is in the region of the middle 
turbinate there is a sense of stuffiness or pressure through the bridge of 
the nose between the eyes. 

(b) If the obstruction in the region of the middle turbinate is great 
enough, or has given rise to a catarrhal inflammation in the anterior 
ethmoidal cells, there may be pain, upon pressure, at the inner angle 
of the orbit under the floor of the frontal sinuses. When pain is elicited 
upon pressure in this region, it is very significant of anterior ethmoidal 
inflammation, and possibly of the frontal sinus as well. 

(c) Frontal headache is frequently present in high deviations, and is 
most severe in the morning upon awakening. If of ocular origin it 
subsides at night and recurs during the day while using the eyes. 

(d) Dizziness or vertigo is sometimes a direct expression of inflamma- 
tion or irritation in the ethmoidal and the frontal sinuses. The dizziness 
is often exaggerated, or is produced by stooping forward or suddenly 
rising from the stooping posture, and is present when the eyes are closed. 
Dizziness or vertigo of ocular origin is often relieved when the eyes are 
closed, as the irritation from the light is thereby eliminated. Dizziness 
of nasal origin is aggravated by jarring the body. 



64 



THE NOSE AND ACCESSORY SINUSES 



Fig. 24 
A 






D 





A. Types of non-obstructive septa: a, deviated from the median line; b, normal straight 
septum in the median line; c, deviation of the lower portion of the septum, with a concavity in 
the left nasal chamber, but with compensatory hypertrophy of the left inferior turbinated body. 

B. Types of obstructive septa: a, ridge pressing against the inferior turbinate; b, ridge pressing 
against the left inferior turbinate and a convexity higher up on the right side obstructing the olfac- 
tory fissure on that side; c, a split septum causing double obstructive convexity of the septum. 

C. a, an S-shaped septum causing obstruction in the inferior portion of the nasal chamber on 
the right side and the superior portion of the chamber on the left side; 6, a high, angular devia- 
tion of the septum causing obstruction of the olfactory fissure of the left side. 

D. a, marked deviation of the septum along the crest, the vomer wedged firmly against the 
left inferior turbinate; b, abscess or hematoma of the septum obstructing both nasal chambers. 



THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 65 

(e) Asthma of reflex nasal origin is sometimes due to intranasal 
pressure and irritation in the middle turbinate and ethmoidal regions. 
This is particularly true when polypi are present. 

(J) The nasal secretions are changed in character and quantity. If a 
chronic catarrhal inflammation of the lower portion of the nasal mucous 
membrane is present the secretions are heavier than normal, and ex- 
pulsion is only accomplished by blowing the nose. If the obstruction is 
in the middle turbinal and ethmoidal regions and a simple inflammation 
is present in the ethmoidal cells the secretion is sometimes watery in 
consistency, though it may be mucoid and quite acrid in character. 
Associated signs of this type of secretion are the reddened and irritated 
appearance of the mucosa and a fissure or eczematous eruption of the 
margins of the nostrils and the upper lip. 

Fig. 25 







( 



.\> 



A traumatic deformity of the external nose and of the septum. The straight dotted line indicates 
the median line of the nose while the curved one indicates the deviation of the septum. 

(g) Postnasal or epipharyngeal " dropping" is usually present. The 
olfactory fissure may be obstructed, and, as the closure prevents drain- 
age through the fissure, the secretions flow backward over the middle 
turbinal into the epipharynx. 

(h) Intermittent stenosis is usually present in those cases in which 
there is an anterior deviation which does not completely block the nasal 
passage. The obstruction interferes with the intake of air, and the 
descent of the diaphragm acts as the piston valve of a syringe and pro- 
duces rarefaction of the air in the nasal chamber posterior to the obstruc- 
tion. This in turn develops turgescence of the erectile tissue and a 
temporary stenosis. 

(i) Alternating stenosis is another sign of an obstructive lesion in the 
lower portion of the nasal chambers and is due to the same causes given 
5 



66 THE NOSE AND ACCESSORY SINUSES 

in the preceding paragraph. The associated disease is usually turges- 
cent rhinitis. 
The Objective Symptoms of Obstructive Deviations. — (a) The 

appearance of the septum and its relation to the various aspects of the 
outer walls of the nose constitute the most important objective symptom. 
For example, if the septum is characterized by a ridge on the left side 
opposite the inferior turbinate and by a convexity in the region of the 
middle turbinate on the right side, an examination shows the deviations 
and the impingement of the same against the inferior turbinate on the 
left side and the middle turbinate on the right side (Fig. 24, B, b). Each 
case should be carefully examined with reference to the equal distribu- 
tion of space in the respiratory tract of the nose and with reference to 
its adequacy for physiological purposes. The various types of deviation, 
of course, present different pictures upon examination, each having its 
peculiar clinical significance in proportion to the degree of obstruction 
caused by it, and in particular to its proximity to the middle turbinated 
body. 

(b) The presence of pus and dried secretions in the olfactory fissure 
between the deviation of the septum and the middle turbinate is sugges- 
tive of the causative relationship of the deviation to the diseased posterior 
ethmoidal sinuses, from which the secretions in all probability flow. 

(c) Hemorrhage or epistaxis is often a sign of a deviated septum, more 
particularly in its lower and anterior portions. A prominent crest pro- 
jecting into the breathway is subjected to an undue exposure to the air 
current and the secretions become dried and adherent to it. When the 
crust is detached, either by blowing or picking the nose, the epithelium 
is torn from the mucous membrane and hemorrhage results. 

(d) External deformity of the nose is often indicative of a correspond- 
ing deviation of the septum (Fig. 25}» 



CHAPTER V 

THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL CORREC- 
TION OF OBSTRUCTIVE MALFORMATIONS OF THE SEPTUM 

There is no cne method of correcting obstructive deviations or mal- 
formations of the septum nasi. The submucous resection of the septum 
is the most nearly universally applicable, though there are some devia- 
tions in which it can be used with great difficulty, whereas another 
method of surgical procedure may be easily and successfully used. Under 
such conditions poor judgment would be shown in selecting the sub- 
mucous operation. In choosing a surgical procedure a method should 
be adopted that will remove the obstructive lesion of the septum with the 
most simple technique and the least risk to the integrity of the nasal 
septum. The object of the operation should be to establish free drainage 
and ventilation of the nasal chambers and of the accessory nasal sinuses 
(see Etiology of the Inflammatory Diseases of the Nose and Accessory 
Sinuses), rather than to exploit one method of operating over another. 
It will be my endeavor, therefore, to give some general rules to guide 
the surgeon in the proper selection of an operation for the correction or 
removal of obstructive lesions of the nasal septum. 

Cartilaginous Deviations.— When the deviation is limited to the 
septal cartilage other operations than the submucous resection may often 
be chosen to correct it; indeed, they may often be chosen in preference to 
the submucous resection. An extreme angular deviation of the septal 
cartilage (Fig. 36) is rather difficult to correct by the submucous method, 
and is easily corrected by the Sluder operation (Figs. 35, 36, and 37). 
The Sluder operation is practically limited to extreme angular devia- 
tions of the cartilaginous septum, as stated by its author. 

A cup-shaped deviation may be corrected by the Asch, the Gleason, 
the Watson, the Price-Brown, or the submucous resection operation. The 
simpler of these procedures are the Watson, the Gleason, and the Price- 
Brown operations, and of these the W 7 atson is, perhaps, the more simple. 
The choice of operation will largely depend upon the location of the cup- 
shaped deviation and the thickness of the cartilage surrounding it. If, 
for example, the cartilage anterior to the deviation is extremely thin, 
or has become fibrous from antecedent chondritis, the triangular flap of 
the Watson operation will not engage against the opposing incised 
cartilage. If, on the other hand, the cartilage anterior to the cup is of 
the usual thickness and texture the Watson operation may be used with 
excellent effect. The cup deviation may also be corrected by the Gleason 
operation if the cartilage below the cup is firm and of the usual thickness. 
The H-incision of Price-Brown is also well adapted to this type of devia- 
tion. The perpendicular incision should be made, one anterior and 

< v 67> 



68 THE NOSE AND ACCESSORY SINUSES 

the other posterior to the cup, and the intersecting horizontal incision 
through the centre of the cup. 

Compound or S-shaped deviations or compound angular deviations 
of the septal cartilage are peculiarly well adapted to the Kyle operation, 
provided the convexities are thickened. The redundancy of cartilage 
may be removed with the V-shaped file saws at the crest of each convex 
surface, thus permitting the septum to be forced to an upright position 
in the median line. This type of deviation is also easily corrected in the 
submucous operation by the author's method with the swivel knife, 
and is perhaps more fully and surely thus corrected. In this type of 
deviation there is usually little difficulty in elevating the mucoperichon- 
drium, after which the cartilage is readily encircled with the swivel knife 
and removal en masse with dressing forceps. 

Simple angular (anteroposterior) deviations and L-shaped angular 
deviations of the septal cartilage are usually very successfully corrected 
by the Watson operation (Figs. 33 and 34), though they are equally well 
adapted to the submucous resection operation with the swivel knife. 

The deviated portion of the cartilaginous septum may be readily 
removed by submucous resection in practically all types of deviations 
except the extreme angular type, and even this may be thus removed. 
It is often preferable, however, to use one of the other methods of operat- 
ing, as they are simpler and almost, if not quite, as satisfactory in their 
results. When, however, the obstructive deviation also involves the 
bony portion of the septum, it is often expedient to adopt a method of 
operating that will be equally applicable to both the cartilaginous and 
bony deviations. Obstructive deviations usually involve both the carti- 
laginous and osseous framework of the septum, hence the indications 
given above are not unqualifiedly applicable, except in deviations limited 
to the cartilaginous portion of the septum. One of the chief objections 
to the operations other than the submucous resection is the necessity of 
wearing a dressing or splint in the nose for two or more weeks. This 
alone should often influence the surgeon to elect the submucous operation. 
Osseous Deviations. — As osseous deviations of the septum are nearly 
always associated with one or the other of the types of cartilaginous devia- 
tions already referred to, a method of operating should be adopted that 
will successfully remove both the cartilaginous and the bony deviations. 
The operation most universally applicable is the submucous resection. 
There are, however, important exceptions to this rule, notably a simple 
spur or ridge, unattended by other deviations of the septum in which the 
obstructive lesions may be removed by Bosworth's method with a saw. 
When the deviation consists of a deflection of the vomer to one side, it 
may be corrected by grasping it with the Asch septum forceps and 
freely fracturing it at the floor of the nose and introducing a nasal splint 
for a few days to hold it in its new position. Another important exception 
is a deviation limited to the perpendicular plate of the ethmoid, which 
may be successfully reduced with Roe's forceps. 

1. A simple spur or ridge may be successfully removed with a saw 
or spokeshave, with less risk to the integrity of the septum than it can 



THE CHOICE OF SEPTUM OPERATIONS go, 

by submucous resection. If, however, the spur or ridge is accompanied 
by a deviation of the cartilage or the perpendicular plate of the ethmoid, 
it may be necessary to adopt some other method of procedure. 

2. Spurs or Ridges Associated with a Cartilaginous Deviation. — 
These types of compound deviation may be effectively corrected by first 
removing the ridge with a saw or spokeshave, and subsequently correct- 
ing the cartilaginous deflection by one of the methods described under 
cartilaginous deviations; or both may be removed at one time by the 
submucous resection operation. 

3. Spurs and Ridges Associated with an Obstructive Deviation of 
the Perpendicular Plate of the Ethmoid. — These types of compound 
osseous deviations may also be corrected by two operations, or by a single 
operation. The ridge or spur may be removed with a saw or spokeshave 
at one time and the deviation of the perpendicular plate of the ethmoid 
corrected at a subsequent time with Roe's crushing forceps. The sub- 
mucous resection operation is usually preferable, as the operation is 
completed at one sitting, and the results obtained are usually much 
better than by the two operations. 

4. A Simple Deviation Limited to the Perpendicular Plate of the 
Ethmoid. — Two operative procedures are applicable to this type of 
deviation, one the Roe operation and the other the submucous resection 
operation. 

As generally practised, the submucous resection operation sacrifices 
more or less of the cartilage whether it is deviated or not. This is done 
to expose the bony parts to operative interference. I have, in a few cases, 
in which the deviation was limited to the perpendicular plate of the 
ethmoid, made the incision just anterior to the union of the cartilage 
and perpendicular plate of the ethmoid, elevating the mucoperiosteum 
over the ethmoid plate on the side of the incisicn, then extending the 
incision through the cartilage and elevating the mucoperiosteum on the 
opposite side of the plate, as is done when the Killian incision is made. 

Principles. — The principles which should guide the operator in select- 
ing an operation other than the submucous resection are the following: 

(a) Never choose an operation which requires the prolonged (more 
than four days) use of an intranasal splint or tampon. The operations 
requiring the prolonged use of a nasal splint or tampon are the Rach 
and the Kyle operations, as the flaps are not self-supporting ; that is, the 
principle of a bevelled edge, or extensive overlapping flaps with union 
by adhesions, cannot be utilized in these operations. 

(b) Operations utilizing bevelled-edged flaps do not require prolonged 
use of splints or tampons; hence, such operations may be chosen in 
selected cartilaginous deviations. The operations utilizing bevelled- 
edged flaps are the Watson, the Gleason, and the Price-Brown 
operations. 

(c) Operations utilizing overlapping flaps with subsequent adhesion 
along the overlapping surfaces may be chosen in extreme angular 
deviation of the cartilaginous portion of the septum. The Sluder 
operation is such an operation. 



70 THE NOSE AND ACCESSORY SINUSES 

(d) Operations in which the bony portion of the septum may be 
fractured or comminuted and reset in any desired position may be per- 
formed in selected cases, in which only the bony portion of the septum 
is deviated. Roe's crushing operation may be selected when only the 
perpendicular plate of the ethmoid bone is deviated. The author's 
method of fracturing the vomer may be chosen when only the vomer 
is deviated. These operations do not require the prolonged use of 
intranasal splints, as bony tissue remains in position without support. 

When the foregoing principles cannot be applied, the submucous 
operation should be used. 



THE SURGICAL CORRECTION OF OBSTRUCTIVE LESIONS OF 
THE NASAL SEPTUM 

Having first determined that the deviation is an obstructive one (see 
Indications), the surgeon should next elect the procedure that will afford 
the greatest amount of correction with the least shock and inconvenience 
to the patient. The type of deviation will have much to do with the 
choice of the operative procedure. No hard-and-fast rules can be laid 
down as to the choice of operation, each case being somewhat different 
from all others. 

The following operative methods will, however, with slight variations 
in technique, meet nearly all the indications for the surgical correction 
of the various types of septal deviations. 

1. Soft Hypertrophies of the Septum.— Soft hypertrophies of the 
mucous membrane of the septum occur at two points, namely: (a) At 
the anterior portion just opposite to or below T the inferior margin of the 
middle turbinated body, and (b) at the posterior end of the vomer. In 
the first instance the enlargement closes the anterior end of the olfactory 
fissure and interferes with the proper ventilation of the superior meatus 
and the sinuses draining into it. Its reduction is best accomplished 
as follows: 

First, induce local anesthesia with a 5 to 10 per cent, solution of cocaine 
applied to the parts with a thin pledget of cotton. 

Second, make one or two linear incisions through the hypertrophied 
tissue with the actual cautery at a bright cherry red heat (Fig. 26). 

This procedure may be repeated two weeks later if the first application 
was insufficient to reduce the mass. 

In posterior hypertrophy of the septum the same procedure may be 
followed, having first reduced the engorgement of the turbinated bodies 
with a spray of 1 to 2000 solution of adrenalin. 

2. Bosworth's Operation.— When the septum is normally placed, 
with the exception of a spur or ridge, the obstructive lesion may be 
removed with a nasal saw (Fig. 27). If the deviation is a pronounced 
one, it may be preferable to resort to the submucous resection operation, 
as all other deflections can be removed by it at one time. 

The technique of the saw operation is as follows: 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



7] 



(a) Induce local anesthesia over the spur or ridge by the application 
of pledgets of cotton saturated with a 5 per cent, solution of cocaine. 
After ten minutes remove the cotton, as anesthesia is usually complete 
in this time. 

Fig. 26 




The reduction of an anterior hypertrophy of the mucous membrane of the septum in the region 
of the anterior end of the middle turbinate: a, linear cauterization; b, cautery electrode making 
a second linear incision. 

Fig. 27 



Bosworth's saw. 



Fig. 28 



Fig. 29 





Saw 



a, ridge or deformity of the septum; 6, the 
inferior turbinate encroached upon by the 
deviation; c, line of incision to be followed 
in removing the ridge with a saw. 



Showing the method of applying the saw 
to remove ridges from the septum. 



(b) Introduce the nasal saw beneath the ridge or spur with its cutting 
edge turned inward and upward, as though it were the intention to saw 
obliquely through the septum (Figs. 28 and 29). 

(c) After the saw is engaged in the bony tissue direct it upward 
(Fig. 29), parallel with the surface of the septum, until tlie ridge or 
spur is completely severed from it. 



72 THE NOSE AND ACCESSORY SINUSES 

It is not necessary to make a preliminary incision along the crest of 
the ridge or spur for the purpose of elevating the mucoperiosteum, as 
experience has shown that healing takes place quite as quickly and satis- 
factorily when the mucoperiosteum is removed with the bone. Healing 
takes place by granulation and the periosteum is extended by the same 
process of repair over the sawn surface. In a number of cases thus 
operated on, and subsequently operated upon by the submucous method, 
I have had little difficulty in elevating the mucoperiosteum over the old 
field of operation. 

The postoperative dressings should be omitted altogether unless the 
method described by Dr. Pischel is adopted. He first secures absolute 
dryness of the wound, and then applies a thin pledget of cotton over 
the surface and saturates it with an ethereal solution of collodion by 
means of a pipette, and allows it to dry in place. The wound is thus 
hermetically sealed with the collodion film, which protects it from the 
nasal secretions. The collodion dressing should be left in position until 
it is voluntarily thrown off, which usually occurs in three or four days. 
Subsequent dressings are not required. 

Fig. 30 

-JL*J !!!g 



Chaleway's spokeshave. 

3. The Removal of Spurs and Ridges with the Spokeshave. — The 

spokeshave may be used instead of the saw, though it is attended by 
more risk to the integrity of the septum and shock to the patient. 
The technique is as follows: 

(a) Local anesthesia. 

(b) Make an elliptical incision around the base of the spur or ridge 
so as to prevent tearing the mucous membrane with the spokeshave 
(Fig. 31). 

(c) Introduce the spokeshave (Fig. 30) into the nostril until its blade 
engages the posterior end of the ridge, and then pull it forward with 
considerable force, again and again if necessary, until it splinters the 
ridge from the septum (Fig. 32). The elliptical incision previously made 
saves the mucous membrane from mutilation. 

(d) The dressing may be omitted or the collodion dressing may be 
used. 

Caution. — So much force is usually required to engage the spokeshave 
that there is danger of fracturing the cribriform plate and causing 
meningitis. 

Another accident which should be taken into consideration is perfora- 
tion of the septum. It is not possible to exercise full control over the 
course of the spokeshave, as it does not cut through the tissue (bony) but 
acts as a wedge. I have sometimes resorted to a procedure which in 
a measure controls the direction of splintering, as follows : 

After making the elliptical incision, grooves are made with a saw at the 



OBSTRUCTIVE LESIOXS OF THE NASAL SEPTUM 



n 



base of the ridge on its upper and lower aspects. The grooves guide 
the spokeshave as it comes forward through the bone, and thus prevents 
cutting too deeply into the tissue. The grooves weaken the attachment 
of the ridge and render its removal possible with less force. 



Fig. 31 



Fig. 32 





Incisions above and below the ridj 



Removal of ridge with the spokeshave. 



The Watson Operation. — The Watson operation consists in making 
ane or more incisions through the septum and then pushing the projecting 
or deviated bevelled portion toward the concave side, the bevelled edges 
formed by the incision retaining the septal flap in its new position. 



Fig. 33 



Fig. 34 





The Watson operation for correcting a simple 
angular deviation of the cartilaginous septum. 



The Watson operation for a combined 
horizontal and perpendicular bowing of 
the nasal septum. 



Technique. — (a) Local anesthesia. 

(b) Make the incision or incisions with a short-bladed bistoury. 

(c) Introduce the index finger or a broad, blunt instrument into the 
nose on the side of the septal convexity and force the deviated flap to the 



74 



TEE NOSE AND ACCESSORY SINUSES 



Fig. 35 



opposite side. If the single incision is made (Fig. 33), force the angular 
flap to the opposite side along the entire line of incision. If the double 

incision (Fig. 34) is made, first force 
the anterior triangular flap (a) to the 
concave side and then force the pos- 
terior triangular flap (b) to the concave 
side. The bevelled edges formed in 
making the incision help to hold the 
flaps in the new position. 

(d) Additional support should be 
given to the flaps by a tampon on the 
side of the convexity or by a septum 
tube splint for a period of three or 
four days. 

Sluder's Operation.— Dr. Green- 
field Sluder has used a modification 
of the Watson operation, with excel- 
lent results, and he especially recom- 
mends it in children with extreme angular cartilaginous deflections. 
Technique. — (r/) Cocaine anesthesia. 

(6) Make three parallel incisions through the entire thickness of the 
septum parallel with the crest (Figs. 35 and 36). The middle incision 




Sluder's septum operation: 1, 2, and 3, the 
lines of incision. 



Fig. 36 



Fig. 37 





Sectional view of the nose before the Sluder 
operation: 1, 2, 3, the lines of incision shown 
in Fig. 35; 4, vhe median line of the nose. 



Sectional view of the nose after the 
Sluder operation: 1, 2. 3, the lines of 
incision as shown in Fig. 35. The bands 
of cartilage overlap, and should be held 
in position with a nasal tube. 



should extend the whole length of the crest. The other incisions are 
made at the apices of the less acute angles 1 and 2. Two strips of 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



75 



cartilage are thus formed, their only attachments being at the anterior 
and posterior extremities. 

(c) Either the upper or lower strip is then forced to the concave side 
with the index finger or a blunt instrument. 

(d) The other strip is likewise displaced to the concave side, thus 
causing them to overlap, as shown in Fig. 37. 

(e) A Mayer nasal tube is then introduced on the side of convexitv 
to hold the strips in position while union takes place, a period of three 
or four days. 

If the opposed surfaces are curetted before coaptation, union will 
take place more rapidly. Dr. Sluder reports 24 cases, 5 in adults and 
19 in children, without perforation of the septum, all of which were 
cases of extreme deflections. 

4. The Gleason Operation.— The election of this operation may be 
made when the septum is bowed or cup-shaped, and without a heavy 
ridge along the crest of the vomer. It consists essentially of a U-shaped 
incision extending either entirely through the septum and both its mucous 
coverings, or only through the mucous membrane of one side and the 
bone and cartilage. The incision may be made with a saw (Fig. 38) 
or with a knife. 



Fig. 38 



Fig. 39 




The Gleason operation. A tongue-flap of the deviated 
portion of the septum. 




Gleason's tongue-flap pushed through 
the window. 



The Technique . — (a) Local anesthesia is induced with a 5 to 10 per 
cent, solution of cocaine applied to the mucous membrane on both sides 
of the septum. 

(6) The nasal saw T is applied on the convex side of the septum at 
its inferior portion, and the incision is carried through the septum in 
an upward direction, the ends of the saw remaining upon the side of 
convexity while its middle portion passes through to the concave or 
opposite side. A U-shaped incision is thus made with a bevelled tongue- 
flap suspended between the limbs of the U (Figs 38 and 39). 

On account of the low position of the nasal orifice the anterior limb 
of the incision is usually too short. This is obviated by removing the 
saw and reinserting it through the anterior limb alone and continuing 



76 



THE NOSE AND ACCESSORY SINUSES 



Fig. 40 



the incision upward, or it may be extended with a knife, as the framework 
of the septum is cartilaginous in this region. 

If it is not desired to extend the incision through the 
mucous membrane on the concave side the saw should 
be directed upward parallel with the septal surface on the 
concave side just beneath the mucous membrane. This 
is not at all difficult, as the mucoperichondrium and peri- 
osteum usually separate very readily from the cartilage and 
bone. Or the membrane may first be elevated on the con- 
cave side by the injection of normal salt solution beneath 
the mucoperichondrium and periosteum, thus lifting it 
away from the cartilage and bone. 

(c) Having made the U-shaped incision, the tongue-flap 
should be forced from the convex side through to the con- 
cave side with the finger inserted into the nostril. The 
bevelled edges of the flap and those of the fixed portion of 
the septum engage so as to hold it in its new position on the concave 
side (Fig. 40). The tongue-flap has a tendency to spring back into its 
former position, owing to the elasticity of the cartilaginous and bony 
tissue contained in it, hence it is necessary to overcome its resiliency 
by forcing it as far to the concave side as possible, the flap being thus 
fractured at its upper extremity. 




a, sectional view 
of the septum 
after the Gleason 
operation. 



Fig. 41. 



Fig. 42 





The Gleason operation, including the quad- 
rilateral cartilage, the perpendicular plate of 
the ethmoid, and the vomer. The incisions a, 
b, c are made with a nasal saw, and incision d 
with a knife. The saw is introduced at the junc- 
tion of the vomer and perpendicular plate, as 
indicated by the swelling of the line a, b. 



The Roe operation. 



By the foregoing procedure the convex portion of the septum is dis- 
placed toward the side of the greatest nasal space, and the obstructed 
side is opened for freer drainage and ventilation. 



OBSTRUCTIVE LESIOXS OF THE NASAL SEPTUM 77 

The Gleason tongue-flap may also be used when the deviation 
embraces both cartilage and bony tissues, as shown in Fig. 41, which 
illustrates a case operated by me with entire success. There was a 
prominent ridge on the left side of the septum corresponding with the 
crests of the crestanasalis and the vomer. The quadrilateral cartilage 
was also deviated to the left. The septum was perforated at the junc- 
tion of the cartilage, perpendicular plate and vomer (dark spot). A 
nasal saw was inserted through this opening and the perpendicular 
plate and membranes cut upward. The vomer was then sawn to the 
floor of the nose. The saw was then directed anteriorly and the vomer 
severed at the floor. (The heavy line shows the area of the incision 
made with the saw, the light line that made with a knife.) A small 
bistoury was used to make the anterior limb of the U-shaped incision. 
The saw and knife should be inserted from the side which will permit 
the bevelled edges to hold the flap in position when pushed through the 
opening. As a large portion of the thickened crest is cartilaginous, it 
will atrophy after being pushed through the window to the opposite 
side. If this fact is not borne in mind, it may appear to the operator 
that the opposite nostril will be occluded, and the patient be left in as 
bad a condition as before the operation. 

Dressings. — It may be necessary to insert a nasal tube (Fig. 47) on 
the side of convexity for a day or two to insure the fixation of the tongue- 
flap in its new position. Dressings are not otherwise needed. 

5. The Roe Operation.— The Roe operation (Fig. 42) may be used to 
correct deviations of the perpendicular plate of the ethmoid bone, and 
it may also be used to correct the bowing of the septum in the region of 
the middle turbinal, where there is also a ridge on the lower portion of 
the septum, though it is not applicable for the correction of an obstruc- 
tion due to a heavy ridge. Roe has devised special forceps, with a male 
and a female blade, for this operation. 

Technique. — (a) Local anesthesia upon both sides of the septum, 
indeed of the whole nasal mucous membrane, is necessary; or the opera- 
tion may be done under general anesthesia. 

(6) The Roe forceps should be introduced, the male blade into the 
side of convexity and the female blade into the opposite side. By closing 
the forceps blades the convex portion of the septum is forced toward the 
opposite side through the opening of the female blade. The entire area 
of obstruction may be thus fractured and forced toward the concave 
side. 

(c) The fractured portion of the septum should be held in its new 
position, with nasal splints, or with strips of bismuth gauze, for a few 
days, or until it becomes fixed in its new position. This operation is 
especially adapted to deviations of the perpendicular plate, which, being 
composed of bony tissue, remains in position after being fractured. 

6. The Asch-Mayer Operation. — This operation consists of a crucial 
incision through the cartilaginous portion of the septum, the four tri- 
angular flaps thus created being pushed toward the side of concavity and 
held in their new position with a Mayer nasal tube (Fig. 47). The opera- 



78 



THE NOSE AND ACCESSORY SINUSES 



tion mav be used in curved or cup-shaped deviations of the cartilaginous 
septum. In other words, the Gleason, Watson, Sluder, Roe, and Asch- 
Mayer operations are suitable for much the same type of deviated septa. 
I have often included the deviated portion of the perpendicular plate of 
the ethmoid in the field of operation with good results, and see no objec- 
tion to it, though the operation as originally devised by Dr. Asch was 
limited to the cartilaginous portion of the septum. 

Technique. — (a) The operation may be performed under local anes- 
thesia, though it is generally preferable to do it under general anesthesia, 
as the shock and pain are otherwise considerable. 



Fig. 43 




Asch's straight scissors. 
Fig. 44 




Asch's curved scissors. 
Fig. 45 




Asch's septum forceps. 



(b) After cleansing the nasal chambers and the face, the straight Asch 
scissors (button-hole) (Figs. 43, 44 and 45) should be introduced into the 
nostrils, the narrower blade into the side of convexity and the wider into 
the opposite, from three-eighths to one-half of an inch above the floor 
of the nose, and the septum cut through. The Asch angular scissors 
(Fig. 44) is then introduced and the perpendicular incision made, 
bisecting the middle of the horizontal one. Four triangular flaps are 
thus made (Fig. 46). 

(c) The septum should next be seized with forceps (Fig. 45) and 
fractured by rotating it from side to side. It has been my practice to 
include the perpendicular plate of the ethmoidal bone in the grasp of the 
septum forceps, as it is nearly always deviated with the cartilaginous 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUXi 



79 



Fig. 46 




portion. I have also included the remnants of the ridge left after the 
sawing operation, thus fracturing it (the vomer) from its attachment to 
the maxilla. 

{d) The index finger is then inserted 
into the nostril on the side of septal 
convexity and the four triangular 
flaps pushed as far as possible to the 
opposite side (Fig. 46), care being 
exercised to fracture the flaps at their 
uncut bases. If this is not done the 
resiliency of the cartilage gradually 
brings them back to their original 
position. 

(e) Severe hemorrhage usually oc- 
curs, but it may be quickly checked 
by the introduction of the Mayer 
nasal tubes. The tubes are primarily 
used, however, for the purpose of 
holding the incised and fractured sep- 
tum toward the concave side (Fig. 
47) The tube selected for the con- 
vex side should be large enough to 
force the septum beyond the point 
it is desired to fix it, as it will sw T ing 
back a little toward its old position in spite of all precautions. A smaller 
tube should be introduced into the opposite nostril to exert counter- 
pressure against the septum to check the hemorrhage. 

After-treatment. — Both tubes should be left in position for two or 
three days and then removed. A tube one size smaller should then be 
introduced into the side of convexity, but none into the opposite side. 
The tubes should be worn for about six weeks, being removed and 
cleansed every alternate day during this period. Experience has shown 
that the septum gradually swings back to its former position if the tube 
is not worn for about this length of time. 



The Asch operation. The crucial incision 
is made through the deviated portion of the 
quadrilateral cartilage of the septum, thus 
forming four non-bevelled triangular flaps. 
The flaps are then pushed forcibly to the 
convex side of the septum and fractured at 
their bases, as shown by the dotted lines. 
This is done to overcome the resiliency of 
the cartilage. 



Fig. 47 




Mayer's nasal tube splints. 



Objections. — (a) Perforation of the septum sometimes follows the 
operation, (b) The shock attending the operation is often great, (c) 
The inflammatory reaction is sometimes severe, (d) The presence of 
the tube in the nose for six weeks is a source of considerable annoyance. 
(e) The hemorrhage is occasionally severe and difficult to control. 



80 



THE NOSE AND ACCESSORY SINUSES 



7. The Kyle Operation. — The Kyle operation may be used in simple 
and compound curvatures of the septum in which there is a redundancy 
of tissue along the lines of convexity. It consists in making V-shaped 
grooves in the septum along the lines of greatest convexity, the object 
being to remove tissue where it is redundant, so that the septum may be 
made straight without overlapping along the lines of incision. 



Fig. 48 



Fetterolf's file saw. 

Technique. — (a) Local anesthesia of both sides of the septum should 
be induced. 

(6) A linear incision with a small bistoury should be made along the 
lines of convexity. 

(c) The Fetterolf V-shaped file saw (Fig. 48) should be used along 
the lines of incision until the thickness of the cartilage and bone are 
penetrated (Fig. 49). 



Fig. 49 



Fig. 50 






Kyle's operation. Side view of the septum 
after groove is made. 



a, sectional view of the septum after the 
V-shaped incision; b, Kyle's malleable 
tube holding the septum in position. 



Fig. 51 




Kyle's malleable tubes. 



(d) The incised septum should then be forced into the median line 
by the introduction of Kyle's malleable tubes into either nasal chamber 
(Figs. 50 and 51). The tube being malleable, may be spread with 



OBSTRUCTIVE LESIONS OE THE NASAL SEPTUM 



81 



forceps introduced into its lumen until the septum is adjusted in the 
median line. 

(e) The after-treatment consists in removing and reintroducing the 
tubes until all tendency of the tissues to return to their former position 
is overcome. 

The Price-Brown Operation. — This operation consists of two parallel 
incisions united by an intersecting incision as shown in Fig. 52. The 
two rectangular flaps thus formed are pushed through to the side of 
the concavity and held in position for a few days with a nasal splint 
or dressing upon the- side of the convexity. The operation is extremely 
simple, and is especially applicable to cup-shaped deviations of the 
cartilaginous portion of the septum. This operation is also appli- 
cable to simple perpendicular or horizontal angular deviations of the 
cartilaginous septum, the intersecting incision being made across 
the crest of the angular deviation, as shown in Fig. 52. The incision 
should be so made that the bevelled edges hold the flap in their new 
position as in the Watson operation. 



Fig. 52 



Fig. 53 




The Price-Brown operation. Two parallel 
incisions are made, one on either side of the 
long axis of the deviation. An intersecting 
incision is then made across the long axis 
of the deviation. All incisions are made 
with bevelled edges, so that when the two 
quadrilateral flaps are pushed to the con- 
cave side they will engage in the opening as 
in the Watson and the Gleason operations. 




The removal of the bony ridge of the septum, 
the preliminary step in Moure's operation, for 
the correction of deviations of the septum. 



Moure's Operation. — Moure's method of straightening the septum is 
especially applicable to those cases in which there is a concavity on one 
side of the septum and a marked thickening or ridge of bone upon the 
opposite side (Fig. 54). This type of deviation is also well suited for 
the submucous operation. 

Technique. — (a) Cocaine anesthesia. 

(b) Remove the ridge with a spokeshave or saw as indicated by 2 in 
Fig. 54. The removal of this ridge of bone materially relieves the pres- 
6 



82 THE NOSE AND ACCESSORY SINUSES 

sure upon the middle (5) and inferior turbinated bodies (4). The septum 
may still crowd too much to the convex side, hence Moure advises the 
following procedure to force the remaining portion of the septum (3) to 
the opposite side: 

(c) Having removed the ridge, two incisions are made, as shown in 
Fig. 55. One is made below the ridge (Fig. 56), and the other above 
and in front of it, parallel with the ridge of the nose. The incisions are 
made with specially devised scissors resembling those of Asch. 

(d) A malleable metal splint is then inserted on the side of convexity 
and spread with forceps until the septum is sufficiently forced to the 
opposite side, as shown in Fig. 57. The two incisions permit the 
septum to be forced to the opposite side, where it should be held with 
the malleable splint until it becomes fixed in its new position. 

After-treatment. — The splint should be removed in three or four days, 
cleansed, and reinserted and moulded to the parts. This procedure 
should be repeated every two or three days for one week, or until firm 
union takes place. Should excessive granulations form they should be 
reduced with fused chromic acid crystals. The open skeleton tube used 
by Moure permits free respiration and nasal irrigation wirile it is in 
position. 

THE SUBMUCOUS RESECTION OF THE SEPTUM 

1 . Position of the Patient. — The patient may be placed in either 
the sitting or the reclining posture. Most operators will probably prefer 
the sitting posture in an ordinary office chair (Figs. 4 and 5), though the 
reclining posture may become necessary if the patient faints either from 
psychical or cocaine depression. I have found, when the patient is thus 
overcome, that the reclining position gives immediate relief, and allows 
the operator to proceed with but slight loss of time. The back of the 
chair should be tipped almost to the horizontal position, and the head 
of the patient supported by a head-rest or by an assistant. When the 
patient is thus reclining the operator should sit by his right side, facing 
the patient. If the operator prefers to stand ; the patient may be placed 
upon an operating table. 

2. Anesthesia. — Cocaine anesthesia is preferable, though a general 
anesthetic may be administered. The method of applying the cocaine 
is important. Freer has called attention to this fact, and, in general, I 
follow his suggestion in reference to it. Pulverized cocaine is used 
instead of a solution. A delicate silver cotton-wound applicator is 
moistened in adrenalin solution, the excess squeezed from it, and then 
dipped into the powdered cocaine. The loose granules are then gently 
knocked off, and the mucous membrane of the entire septum on both 
sides is thoroughly massaged or rubbed with it. The membranes should 
be massaged for about three minutes. After an interval of five minutes 
they should be massaged again with a fresh preparation. Three appli- 
cations usually induce complete anesthesia, though in rare instances 
numerous applications are required. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 83 

Fig. 55 




Cross-section of the nose, illustrating certain 
details of Moure's septum operation: 1, the 
ridge severed with the spokeshave; 2, the in- 
cision with the spokeshave; 3, the septum; 4, 
the inferior turbinate crowded upon by the 
ridge of the septum; 5, the middle turbinate 
also crowded upon by the deviated septum. 

Fig. 56 



The incisions of the septum in Moure's oper- 
ation : 1, the incision along the floor of the nose 
below the septal ridge; 2, the thickened septal 
ridge; 3, the upper incision through the septum 
being made with Moure's scissors. 



Fig. 57 



VnjI/>- 




Making the incisions through the septum 
with Moure's scissors: 1, Moore's scissors; 2, 
the septum. 



Moure's malleable splint in operation: 

1, the septum displaced to the right side 
of the nose; 2, the incision made with 
Moure's septum scissors; 3, the outer wall of 
the nasal splint resting against the inferior 
turbinated body; 3', the inner wall of 
Moure's nasal splint crowding the septum 
to the right side of the nose. 



84 



THE NOSE AND ACCESSORY SINUSES 



The advantages of this method of applying cocaine over the use of 
solutions are the speed with which anesthesia is induced and the com- 
parative infrequency of cocaine toxemia. By this method little or no 
cocaine is swallowed, whereas when a solution is used a considerable 
amount may be swallowed and produce toxic symptoms. 

When Hajek's incision is made at the anterior end of the columnar 
cartilage (Fig. 58), Schleich's solution should be injected beneath the 
membrane, as the application of cocaine will not produce anesthesia. 
Furthermore, the membrane is very adherent in this region (vestibular 
portion of the septum) and is elevated with difficulty. The subcutaneous 
injection of the solution partially elevates the membrane and renders 
the completion of the elevation comparatively easy. 



Fig. 58 



Fig. 59 




Incisions for the sub- 
mucous resection of the 
septum: a, the Hajek 
incision; b, the Killian 
incision. 



The elevation of the mucoperichondrium upon the side of the 
primary incision in the mucous membrane. The elevation is 
begun with a sharp or semisharp elevator and is completed with 
the blunt elevator. 



3. The Incision.— The choice of the location of the incisions should 
depend upon the character and location of the septal deviation. If it 
extends into the vestibule of the nose, Hajek's incision should be made at 
the extreme anterior margin of the cartilage of the septum, as shown in 
Fig. 58, a. As the membrane of the vestibular portion of the septum is 
firmly attached to the fibrocartilage beneath it, this incision should only 
be made when the deflection is far enough forward to render it necessary 
to remove the anterior portion of the deflected cartilage. 

When the deviation does not extend forward into the vestibule, Killian's 



THE SUBMUCOUS RESECTION OF THE SEPTUM 85 

incision (Fig. 58, b) should be made at the junction of the vestibular 
membrane with the mucous membrane of the septum, as the muco- 
perichondrium elevates with comparative ease posterior to this point. 

The Killian incision is usually preferable and should be made with 
a sharp-pointed knife upon the left side of the septum. All other writers 
have recommended that it be made upon the side of the convexity of 
the septum, as they believe this allows greater freedom of access in 
elevating the membrane over the region of convexity. I believe this to 
be ill advised, as most operators are more dextrous with their right 
hands. Furthermore, it is unnecessary, as the tip of the nose is flexible 
and may be turned to one side out of the way. Hence I recommend 
that the incision be made upon the left side of the septum except for 
left-handed or ambidextrous surgeons. 

The tip of the index finger of the left hand should be introduced into 
the right nasal chamber to exert counterpressure while the incision is 
being made. The incision should only extend through the mucous 
membrane and perichondrium. If it is carried deeper it interferes 
with the elevation of these tissues. 

4. The Elevation of the Mucoperichondrium and Periosteum.— 
This step of the operation is often the beginning of either success or failure 
in the operation. If the elevation is properly done over the entire area 
of the deviation on both sides of the septum, the subsequent steps are 
comparatively easy to carry out. If, however, the elevation is not properly 
executed and extended over the entire field of the deviation, it may 
interfere with the remaining steps of the operation to such an extent as 
to defeat its purpose. Many of the younger rhinologists have told me 
of the difficulties they have encountered, and almost without exception 
they have failed to elevate over a large enough field. In the average 
case in which the cartilage, perpendicular plate of the ethmoid, and the 
vomer are involved in the deviation, the membrane should be elevated 
over almost the entire area of both sides of the septum. If, however, 
only the cartilage of the septum is affected, the elevation should be 
extended about one-half inch beyond the junction of the cartilage and 
the perpendicular plate, and down to the floor of the nose. Always 
elevate at least one-half inch beyond the area of the tissue to be removed, 
as otherwise the membrane may be injured in the process of removing 
the deviated portion of the framework of the septum. 

The technique elevation of the mucoperichondrium may be accom- 
plished in various ways. Some operators, notably Freer, prefer small, 
thin, sharp elevators with which the mucoperichondrium and periosteum 
are dissected from the framework of the septum. Curved elevators are 
also used to work around curved portions of the septum. Personally, 
I prefer heavy, broad and dull elevators, and I have never found it neces- 
sary to use curved elevators to get around a curved or an angular devia- 
tion. A study of the following descriptive technique will show how 
the heavy blunt elevators may be successfully used to encompass curved 
and angular deviations of the cartilage and the perpendicular plate of 
the ethmoid. The chief reason for using the blunt heavy elevators is 



gg THE NOSE AND ACCESSORY SINUSES 

the greater speed and the lessened liability of tearing the membrane 
in the process of elevation. 

To start the elevation a sharp or semisharp elevator should be used 
(Fig. 78), care being exercised to get beneath the perichondrium. If the 
elevator penetrates between the mucous membrane and perichondrium, 
the surface of the cartilage will present a velvety red appearance as the 
perichondrium is still covering it. If, however, the elevator penetrates 
beneath the perichondrium the exposed cartilage presents a glistening 
white surface. Great patience is often required to start the elevation 
properly; this being done, the remaining elevation is comparatively 
easy. The point of least resistance is usually at the upper portion of 
the Killian incision, whereas at the lower portion the perichondrium is 
often so adherent as to require a knife to separate it from the cartilage. 



Fig. 60 




The Hajek elevator introduced beneath the 
mueoperichondrium along the line of least resist- 
ance. When thus introduced the elevation 
should be made in the whole shank of the 
instrument in a downward and backward direc- 
tion to the crest of the vomer. The periosteum 
along the crest of the vomer should then be 
incised, as shown in Figs. 61, 62, 63, and 64. 




Section through the nasal septum: a, quad- 
rilateral cartilage; b, vomer; c, c, agglutina- 
tion of the perichondrium to the periosteum; 
d, d, periosteum reflected over the crest of 
the vomer (it is not continuous within the 
perichondrium); e, e, mueoperichondrium. 



Having succeeded in starting the elevation (Fig. 59) abandon the sharp 
elevator and insert the blunt one (Fig. 78) into the small pocket already 
made. Direct the elevator parallel with the ridge of the nose, as this 
is the direction of least resistance (Fig. 60). Having introduced the 
elevator almost to the cribriform plate the elevation should be continued 
backward and downward with the whole length of the shank of the 
elevator within the pocket of the membrane. The mistake is usually 
made of attempting to elevate with the tip of the elevator, whereas it 
should be done with the shank. With the former it is easy to tear the 
mueoperichondrium, while with the latter the elevation may be rapidly 
accomplished with but little danger of tearing it. The principle in- 
volved is obvious, namely, a small tip will perforate more readily than 
a long shank. As a matter of fact, the mueoperichondrium and peri- 
osteum elevate readily under moderate tension with a broad dull 



THE SUBMUCOUS RESECTION OF THE SEPTUM 87 

instrument, whereas if a small sharp elevator is used extreme care must 
be constantly exerted to avoid making a perforation. 

After introducing the heavy blunt elevator as high as the cribriform 
plate (Fig. 60), exert pressure downward and backward with a twisting 
motion, and, as a rule, the membrane will strip down to the crest of the 
vomer in a few seconds, or at most in a minute or two. Five minutes 
or more may be required to start the elevation, whereas to complete it 
will require but a comparatively short time. 

The question naturally arises, How can the elevation be accomplished 
with the shank of the elevator when the cartilaginous or perpendicular 
plate portion of the septum is convex? The operator should remember 
that these portions of the septum are thin and flexible. Being so, they 
may be forced with the elevator to the median line and thus temporarily 
rendered straight. While held in this straightened position the shank of 
the instrument is passed downward and backward, elevating the mem- 
brane as it proceeds. I have rarely observed a septum in more than 400 
submucous operations that did not yield to this method of procedure. 
It may also be asked, How can the elevation he accomplished with the 
tip of the straight, blunt elevator when there is a perpendicular deviation 
of the cartilage? 

The procedure is very simple. The tip of the nose is flexible, and 
the instrument should be held parallel with the anterior portion of the 
cartilage until it reaches the crest of the perpendicular deviation. The 
instrument should then be shifted until it is parallel with the cartilage 
posterior to the crest. The flexibility of the tip of the nose makes this 
possible, hence a curved elevator is not necessary for the purpose; or 
the crest may be forced to the concave side, thus rendering it straight 
and the elevation continued. My contention in favor of the use of blunt 
elevators (after the elevation is started) is based upon the conviction 
that the average operator will do less damage and will operate with 
greater speed than he will with small sharp elevators, or with small 
blunt ones. Otherwise, I have no objection to Freer's elevators, with 
which he, with infinite pains, accomplishes good results. 

According to Neumann (J. R, Fletcher), the development of the peri- 
osteum of the septum nasi throws interesting light upon the technique 
of the submucous resection of the septum. He has found upon histo- 
logical examinations of sections of the septum that the periosteum is not 
uniformly reflected over the bony portion of the septum. That only where 
bone unites with bone, as where the perpendicular plate of the ethmoid 
unites with the vomer, is the periosteum continuously spread over the 
septum; and that where the vomer unites with the cartilage of the septum, 
the periosteum is not continuous with the perichondrium of the cartilage. 
In the latter region the periosteum arises from the floor of the nose and 
passes upward over the lateral surface of the vomer to its crest, over 
which it is reflected, and then passes downward over the opposite 
lateral wall of the vomer to the floor of the nose. He also claims that 
the perichondrium is reflected over the periosteum in this region and 
that it is closely adherent to it (Figs. 61 and 62). 



88 THE NOSE AND ACCESSORY SINUSES 

This arrangement of the periosteum and perichondrium explains 
the well-recognized difficulty experienced in elevating the periosteum 
below the crest of the anterior portion of the vomer when the elevation 





Elevation of the membranes of the cartilage 
and vomer: a, quadrilateral cartilage; b, vomer; 
c, c, perichondrium: d, d, periosteum of vomer 
with two incisions (f, f) at the crest; e, mucous 
membrane; /, f, two incisions through the peri- 
osteum along the crest of the vomer, to facilitate 
the elevation of the membranes anterior to the 
junction of the perpendicular plate of the 
ethmoid with the vomer. 



o, cartilage; b, vomer; c, c, perichondrium; 
d, d, periosteum of the vomer; e, e, mucous 
membrane; /, two incisions through the peri- 
osteum along the crest of the vomer. On the 
concave side the periosteum over the vomer 
is elevated. 



Fig. 64 



is begun above it. I have long recognized this difficulty and attributed 
it to fibrous prolongations from the periosteum to the vomer, which, 
according to Carter, were due to the presence of the tuberculum or 

gland in this region. It appears, how- 
ever, from the investigations of Neu- 
mann that this is not the true explana- 
tion. 

The elevation should be begun along 
the ridge of the nose, as shown in Fig. 
60, and carried down to the upper 
border of the vomer with the whole 
length of the elevator. The ele- 
vator should then be removed and a 
short-bladed scalpel introduced and 
an incision made with it along the 
1 $!bk ^fv^A cres * an terior to the perpendicular 

^^ plate of the ethmoid (Figs. 62, 63, 

showing the line of incision (a, a) through and 64). The elevator should then be 
the periosteum along the crest of the reintroduced and the elevation (on the 

vomer to facilitate the elevation of the • i p ♦. « .1 . \ 

membranes. A similar incision should be S . lde -° [ ^OllCaVltv ot the Septum) COn- 

mide on the opposite side of the crest, tinued to the floor of the nose. Pos- 
terior to the cartilage the elevation is 
easily made to the floor of the nose as the periosteum is continuous 
from the roof to the floor of the nose. 




THE SUBMUCOUS RESECTION OF THE SEPTUM 



89 



I have often noted the liability of the mucoperiosteum to tear at the 
junction of the vomer with the cartilage. Neumann's findings, 



Fig. 65 




The mucoperichondrium being elevated, the cartilage is incised, care being exercised to avoid 
perforating the mucoperichondrium upon the opposite side of the septum. 

Fig. 06 




The cartilage being incised, the mucoperichondrium of the opposite side of the septum is being 
elevated. The elevation is begun with a sharp or semisharp elevator, and is completed with a 
blunt elevator. 



90 



THE NOSE AND ACCESSORY SINUSES 



namelv, the close adherence of the mucoperichondrium to the under- 
lying periosteum and the reflection of the periosteum oyer the crest, 
adequately explain it. This knowledge, and the periosteal incisions I 
have recommended, greatly facilitates the elevation and reduces the 
liability of perforations. 

5. The Incision through the Cartilage.— The incision through the 
cartilage (after Killian's incision) may be made with a small short-bladed 
sharp knife, though it may be done with the tip of a curette or other 
semisharp instrument. Some operators prefer the latter method, believ- 
ing there is less danger of perforating the opposite mucous membrane. 
If a knife is used the tip of the finger should be placed in the opposite 
nostril to exert counterpressure while the incision is being made (Fig. 65). 
The cartilage should be incised very cautiously, almost cell by cell, with 
very delicate pressure, until the tip of the instrument is felt through the 
thickness of the opposing mucoperichondrium. Under no circumstance 
should the opposite mucoperichondrium be incised, as this would cause 
a permanent perforation of the septum unless the incision were im- 
mediately closed with sutures. I wish to emphasize the fact that if 
both mucous membranes are perforated, at points exactly opposite, 
a permanent perforation will follow unless one is sutured by Yank- 
auer's method. If the perforations are not opposite, a permanent per- 
foration will not result, though the process of repair will be prolonged. 

If the incision through the cartilage is made 
Fig. 67 with a curette or other semisharp instrument, 

the finger should be placed in the opposite nostril 
to exert counterpressure while the instrument is 
being ground through the cartilage. The tip of 
the finger enables the operator to detect when 
the entire thickness of the cartilage is penetrated. 
The cartilage should be incised in a line corre- 
sponding with the Killian incision. If, however, 
the Hajek incision is made the cartilage is not 
incised, as the incision is anterior to its forward 
extension. When this incision is made the muco- 
cutaneous membrane is dissected from both 
sides of the fibrocartilage of the septum with a 
small, sharp knife. 

6. The Elevation of the Opposite Muco- 
perichondrium and Periosteum. — When the 
cartilage is completely incised, the semisharp 
elevator (Fig. 66), with its flat surface in appo- 
sition with the cartilage, is inserted into the carti- 
laginous incision. The sharp edge of the tip of 
the elevator should be moved up and down between the edge of the 
cartilage and the adherent mucoperichondrium, especially at the upper 
limit of the incision, as the membrane is less adherent at this point (Fig. 
66). Having started the elevation the blunt elevator should be intro- 
duced and passed upward parallel with the ridge of the nose (direction 




Showing the Foster sep- 
tum speculum in position 
after the membranes are 
elevated. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



91 



of least resistance) until its tip is near the cribriform plate of the ethmoid 
bone. The elevation should then be continued downward and backward, 
with the shank of the instrument as previously described, and extending 
over an area considerably larger than the area of cartilage and bone 
to be removed. Never attempt to elevate below the crest of the vomer 
when it forms a dense bony ridge, as to do so would only result in an 
extensive laceration of the membrane. (See Removal of the Vomer.) 

7. The Removal of the Cartilaginous Portion of the Septum.— In 
nearly all cases this is most easily accomplished with my swivel knife 
(Figs. 69 and 76), though it may be done with Killian's double-edged 
spokeshave, a biting forceps, or angular knives. The advantage of the 
swivel knife is the ease, precision, and rapidity with which it encircles 
the cartilage, and the further fact that it removes it in one piece, thus 
allowing the operator to study the specimen as a whole. 



Fig. 68 




The removal of the quadrilateral cartilage of the septum with the author's swivel knife. The 
membrane is shown removed to expose the knife to view. In the actual operation the membrane 
is not removed. 



Before using the swivel knife the mucoperichondria should be distended 
with a septum speculum (Figs. 67 and 84) to lift them from the cartilage 
and to provide room for the swivel knife. This exposes the cartilage to 
full view. The swivel knife may be applied to the cartilage at either 
the upper or lower portion of the incision. If to the upper portion, the 
incision will be made upward, backward, downward, and finally forward, 
along the floor of the nose, thus completely encircling the portion of the 
cartilage to be removed (Fig. 68). If applied at the lower portion of the 
incision, the cut will extend backward, along the crest of the vomer to the 
junction of the vomer and perpendicular plate of the ethmoid, thence 
upward and forward, along the anteroinferior margin of the perpen- 
dicular plate, and then downward, parallel with the ridge of the nose to 
the upper limit of the primary incision of the cartilage, thus encircling 
the portion of the cartilage to be removed (Fig. 69). If the incision is 



92 



THE XOSE AXD ACCESSORY SINUSES 



begun at the lower limit of the primary incision it may be necessary 
first to make a slight cut with a knife or scissors, as the cartilage is 
often fibrous at this point. 

Fig. 69 - 




The author's swivel knife in position at the lower portion of the incision of the cartilage. 

Fin. 70 




The cartilage, having been excised submucously with the swivel knife, is removed from the 
mucoperichondrial pouch with dressing forceps. 

The swivel knife is easily controlled and is an instrument of great 
precision. The swivel blade follows the direction toward which the 
tips of the prong are directed. The resistance of the tissues controls 
the position of the swivel blade so that it always follows the prong-tips. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



93 



This instrument was suggested by Killian's fixed double-edged septum 
cartilage spokeshave, though the swivel blade is an entirely new prin- 
ciple in surgical instruments. While the general appearance of the 



Fig. 71 




Showing the mucoperichondrial pouch after the removal of the cartilage. The bony crest of the 
vomer is shown in the bottom of the pouch, while deep in the pouch is shown the perpendicular 
plate of the ethmoid extending upward from the crest of the vomer. This should be removed 
with the Ballenger-Foster forceps, as shown in Fig. 72. 

Fig. 72 







. The removal of the perpendicular plate of the ethmoid bone with the Foster- Rallenger forceps: 
a, the area of cartilage previously removed with the swivel knife; b, the area of perpendicular plate 
removed with the Foster-Ballenger forceps. 

instruments are much alike, the swivel principle in my knife makes 
it quite different. They are alike only in the fact that the handle and 
prongs are similar. 

Having encircled the cartilage, it is removed en masse, with dressing- 
forceps, as shown in Fig. 70. Fig. 71 shows the perpendicular plate 



94 



THE NOSE AND ACCESSORY SINUSES 



in the depth of the mucoperichondrial pouch after the cartilage is 
removed. 

8. The Removal of the Perpendicular Plate of the Ethmoid. — This 
is accomplished with the Foster-Ballenger bone forceps (Fig. 77). They 
remove a comparatively large piece at each bite, and two or three bites 
remove all that is necessary. The bites may be made without removing 
the forceps from the mucoperichondrial pouch (Figs. 72 and 77), a point 
of considerable importance, as each introduction of an instrument into 
the perichondria] pouch increases the chance of in jurying the membranes. 
The perpendicular plate may also be removed by seizing it with heavy 
dressing forceps and twisting it from its attachments, though this is a 
crude and dangerous method, as it may fracture the cribriform plate. 



Fig. 73 




The removal of the thickened crest of the vomer with the author's V-shaped gouge. 

9. The Removal of the Vomer. — Various methods are in vogue for 
the removal of the deviated vomer, which often forms the so-called 
ridge of the septum. It is obviously almost impossible to elevate the 
mucoperiosteum beneath the crest of the ridge (vomer), as its anterior 
portion is near the floor of the nose, and to attempt to pass the elevator 
over the margin of the crest would almost certainly tear the tense mucous 
membrane along this line. Fortunately it is not necessary to elevate 
below the crest, as the deviated or thickened bone can be removed 
without previously elevating the membrane beneath the crest. 

An old and approved method of removing the vomer is w T ith Hajek's 
gouge or some modification of it (Figs. 73, 80 and 81). The V-shaped end 
of the gouge is engaged at the anterior end of the ridge of bone and driven 
with a mallet into its substance for a short distance, and then the handle 



THE SUBMUCOUS RESECTION OF THE SEPTUM 95 

Fig. 74 




The author's method of removing the ridge of bone in the submucous resection of the septum: 
a, the septum forceps grasping the ridge, the blades being external to the mucous membranes. 
The forceps is rotated on its longitudinal axis, as in the Asch operation, thus fracturing the vomer 
from its lower attachment; b, the area of cartilage and" perpendicular plate of the ethmoid pre- 
viously removed; the mucous membrane is shown removed, though this is not actually done in 
the operation. 



Fig. 75 



of the gouge is depressed, and thus partially splinters the bone from its 

attachment. The gouge is then driven farther into the ridge until it 

is finally removed in its entirety. As 

the vomer is loosened it separates 

from the mucoperiosteum without 

tearing it, provided, of course, the 

gouge is always directed parallel 

with the anteroposterior direction of 

the crest of the vomer. 

Another method of removing the 
deviated vomer is with a specially 
devised bone-cutting forceps. Of 
these, L. M. Hurd's is probably the 
best (Fig. 82). It is powerful, has 
downward cutting blades, and with 
it the bone may be bitten away with 
considerable ease. 

R. H. Brown has devised a 
guarded drill, to be used with an 
electric motor for the submucous 
removal of the deviated vomer. 

Personally, I prefer to first frac- 
ture the vomer from the premax- 
illary bone at the floor of the nose, 
and then to remove it with heavy 
dressing forceps, introduced into the mucoperiosteal pouch. During 
the process of fracture the mucoperiosteum separates from beneath 




The removal of the vomer after it i^ fractured 
is shown in Fig. 74. 



96 



THE NOSE AND ACCESSORY SINUSES 



the crest of the vomer and thus allows the long ridge of bone to be re- 
moved from the pouch (Fig. 75). In young adults and children my 
method is not applicable, as the vomer is not yet fully ossified. In 



Fig. 76 







The author's swivel cartilage knife. 




Foster-Bailenger perpendicular plate bone forceps. 
Fig. 78 

Hajek-Ballenger mucoperichondria elevators. 
Fig. 79 



The author's mucosa knife. 
Fig. 80 




Hajek's septum gouge. 
Fig. 81 



sir "Ml HI I II 111 ilHI II ill 1 1 1 ! If il I ! Ill I II 



IMHITin I HBH11iTjj1jlljTI!BffHq^ 



EAiHSRD/S CD, CHICAGO 
The author's septum gouge. 



adults it is a speedy and an almost painless procedure, and results in 
but little or no shock, as the cartilage and perpendicular plate of the 
septum have been previously removed. There is, therefore, no solid 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



97 



tissue above to communicate the shock to the cranial contents (Fig. 74). 
The technique of the procedure is as follows: 

Introduce the blades of the Asch septum forceps into the nasal cham- 
bers outside of the mucoperichoiidria, and grasp the deviated vomer 
firmly, twisting the forceps in its longitudinal axis and fracturing the 
vomer from its attachment at the floor of the nose. The blades of the 
Asch forceps should be placed a little above the floor of the nose, as thev 
may otherwise tear the mucous membrane at the junction of the vomer 



Fig. 82 



Fig. 83 





Hurd's bone septum forceps. 
Fig. 84 



FAHARDY8CQ, 
CHICAGO. 



Allen's nasal speculum. 
Fig. 85 





Ballenger-Foster septum speculum. 



Simpson's nasal sponge splint. 



with the floor of the nose. The fracture should be thorough, in order 
to permit the detachment of the fragments from the floor of the nose. 
Remove the Asch forceps and introduce the tips of heavy dressing for- 
ceps into the mucoperichondrial pouch, grasp the vomer, and with a 
tugging, teasing motion lift it from its fractured base. The mucoperi- 
osteum remaining attached below the crest will readily separate and 
allow the bone to be removed (Fig. 75). 

10. Inspection of the Field Operated Upon.— After the completion 
of the various steps of the operation, the field operated upon should be 
7 



THE NOSE AND ACCESSORY SINUSES 



subjected to the closest scrutiny. If a portion of the deviated cartilage 
or bone is left in place it may be found, when healing is complete, that 
it will still cause obstruction of the nasal chambers. Every vestige of the 
deviated framework of the septum should be removed (Dundas Grant). 
Bone-cutting forceps of one type or another are usually used for this 
purpose in the cartilaginous and perpendicular plate portions of the 
septum, though the gouge may be more useful for cutting along the floor 
of the nose. I have found it a very helpful practice to insert a finger an 
inch or two into the nasal chambers, as it enables me to detect the presence 
of bony prominences which might otherwise have escaped my notice. 

11. The Dressing. — A dressing should be placed in the nasal chambers 
for two purposes, namely: (a) Coaptation of the membranes, and (b) pre- 
vention of the formation of a blood clot in the mucoperichondrial pouch. 
The dressing most frequently used is composed of compressed cotton 
or Berney's sponge tents. They have been placed on the market under 
the name of the Simpson-Berney nasal splints (Fig. 85). The mucoperi- 
chondria are first clamped together with the septum speculum, then one 
or two of the splints are introduced into each nasal chamber. The 

patient's head is then inclined 
backward and a few drops of 
distilled water, or of the peroxide 
of hydrogen, are instilled into the 
ends of the splints (Fig. 86). This 
causes them to swell and compress 
the membranes together. 

12. The After-treatment.— The 
nasal dressing should be removed 
in from twenty-four to forty-eight 
hours after the operation. The use 
of bismuth paste on the splints has 
a chemo tactic effect (reaction of 
inflammation) upon the mucous 
membranes (Emil Beck) and thus 
reduces the chance of infection. 
The splints interfere with the ven- 
tilation and drainage of the nose, 
and are therefore usually removed 
at the expiration of twenty-four to 
forty-eight hours. Subsequently 
the nasal chambers are irrigated 
with a mild solution of the per- 
manganate of potash three or four 
times daily. The temperature of 
the solution should be about 104° 
F., or as hot as the patient will 
tolerate. If crusts form over the incision the patient should be pro- 
vided with a tube of sterile vaseline and instructed to squeeze some of 
it into the vestibules of the nose, twice a day, and to compress the 




The Simpson sponge-tent dressing in posi- 
tion at the close of the submucous operation. 
The left side shows the tents dry, the right moist 
and swollen. The Foster speculum holds the 
membranes in apposition while the tents are 
being introduced. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 99 

ahe of the nose and thus smear it over the mucous membranes. Heal- 
ing should be completed in from three to ten days, unless one of the 
membranes has been lacerated, in which event it may be somewhat 
prolonged. 

Accidents. — This operation is peculiarly liable to certain accidental 
complications, some of which are inherent in the difficult technique, 
while others are the results of the inexperience or temperamental weak- 
nesses of the operator. 

Incision through Both Mucous Membranes. — The novice is likely to 
extend the incision through both mucous membranes, as the cartilage 
is easily incised and the most delicate manipulation of the knife is 
necessary in making the incision through it. Before the operator realizes 
it the incision has extended through the mucous membrane upon the 
opposite side, To avoid this accident the cartilage should be incised, 
cell by cell, as it were, until the point of the knife is perceived by the 
tip of the index finger, which is in the opposite nostril. Should both 
mucous membranes be incised along the line of the Killian incision it 
will be necessary to" close one of the incisions with Yankauer's needles 
and methods of suture. The sutures should be removed at the expira- 
tion of the third day. 

Tears through Both Mucous Membranes. — Sometimes during the 
process of elevating them, the mucous membranes are lacerated at points 
exactly opposite. Should this accident occur an endeavor should be 
made to close one of the apertures by Yankauer's method of suturing, 
or to reintroduce the cartilage removed from the septum as suggested 
and practised by Dr. P. G. Goldsmith, of Toronto. (See Perforation 
of the Septum, at the end of this chapter.) 

Destruction of the Mucous Membrane upon One Side of the Septum. — 
This accident may occur during the elevation of the membrane or during 
the removal of the cartilaginous and bony portions of the septum with 
cutting forceps. This is especially true if the elevation of the muco- 
periosteum has not been extended over a sufficiently large area. It 
may also occur while the cutting forceps are in use, the mucous mem- 
brane being accidentally engaged in the forceps. This can be avoided 
by exercising great care through observation before closing the forceps. 

Sinking in of the Ridge of the Nose. — This accident has been reported 
only a few times and need not be feared except under a few conditions. 
When it occurs it is due to one of three conditions : (a) The removal of 
the cartilage too near the ridge of the nose, (6) chondritis following 
or preceding the operation, and (c) traumatism. 

(a) A cartilaginous ridge at least one-fourth of an inch in depth 
should be left to support the external nose. A greater width is desirable, 
especially if the deviation is traumatic in origin, as in this case chon- 
dritis may have weakened the cartilage. 

(b) Chondritis or inflammation of the cartilage following the operation 
may soften the cartilage of the ridge of the nose and cause it to drop 
or sink in and thus produce external deformity. The nose should be 
carefully observed for several days after the operation for inflamma- 



100 



THE NOSE AND ACCESSORY SINUSES 



torv symptoms, and if they occur strenuous efforts should be made to 
combat them. Perhaps the best procedure is to employ heat over the 
nose. The application of hot fomentations every fifteen minutes is the 
best mode of procedure. In addition. to this the nasal chambers should 
be irrigated with normal salt solution (one teaspoonful of table salt to 
each pint of water) every three hours. The head should be inclined 
well forward, almost between the knees, and the mouth kept open 
during the irrigations. These precautions prevent the patient swallow- 
ing and carrying the solution to the tympanic cavities, in which case it 
might produce otitis media or mastoiditis. 

When the ridge of the nose sinks in after submucous resection of the 
septum, it is sometimes possible to correct the deformity by the sub- 
cutaneous injection of cold paraffin. 

(c) A blow upon the nose after the submucous resection operation 
might cause a sinking-in of the ridge below T the nasal bones. I have 
never known of such an accident, though I presume it will occur in a 
few cases in due course of time, as the cartilaginous support of the 
nose is weakened by the submucous operation. 

The Freer or Open Method.— According to O. T. Freer, this pro- 
cedure is especially adapted to cases in which unusual difficulties neces- 
sitate an operative field as open as possible for inspection, as those in 
which the mucous coverings are very adherent, or in which the operation 
is performed in the small nostrils of children, for deviations with extreme 
angles or for extensive deep-seated deflections. The open operative field 
is obtained by means of Freer's reversed L mucous membrane incision 
(Fig. 87), consisting of a vertical limb, made well back in the nose, 
joined by a horizontal one conducted forward from it along the base of 
the septum, in most cases to the front of the nasal vestibule. These 
incisions outline a flap which is dissected upward and backward with a 
suitable blade from its basal line until the vertical incision is reached 

(Fig. 87). The flap is then uplifted 
by means of the dulled elevator and 
held forward out of the way by the 
use of a retractor, by means of 
which the nose is held open by an 
assistant, these retractors taking the 
place of a speculum. A large field of 
cartilage is thus uncovered in front 
so that the first incision through it 
can be made in plain view. It out- 
lines a tongue-shaped flap of cartilage 
with its base backward, and which, 
when uplifted from the mucous cov- 
erings of the concave side of the de- 
viation gives a broad entrance into 
the concavity of the deflection, making 
all of its recesses readily accessible to sight as the denudation progresses, 
so that sharp dissection can be safely accomplished without risk of per- 



Fig. 87 




a, a, Free 



r s incision. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 101 

foration. After the posterior portion of the mucous coverings have then 
been uplifted on the side of the convexity of the deviation, the cartilage, 
now entirely denuded, is excised with a little keen, hoe-shaped blade 
and by sharp elevators. The remains of the cartilage are then detached 
posteriorly from their usual attachments to the side of the vomer by 
means of long elevators; and the bony resection is begun by an incision 
upon the upper border of the ridge (often hidden) and anterior border of 
the vomer, splitting the periosteal envelope of these structures. The 
periosteum is then pushed off from their convex and concave sides by 
means of suitable chisel-edged raspatories and blades and the entire bony 
deviation bared by them and by the elevators. It is then cut away by 
the Freer reinforced punch forceps, including the ridge of the nasal floor, 
and as much of the vomer and perpendicular plate as is needed. The 
chisel should only be used in cases in which the ridge is unusually broad. 

Freer operates with the patient in a semirecumbent position on a 
dental chair, which can be raised and lowered. He employes the Kir- 
stein head lamp, and stands beside the patient. 

He has devised a special instrumentarium for the operation. It 
includes a number of keen-edged blades for dissection, which he uses 
whenever, in his opinion, the coverings of the deviation cannot be 
uplifted readily with dull-edged instruments. 

After the operation, the nostril of the side on which the incisions 
have been made, should be packed with narrow strips of lint saturated 
with bismuth subnitrate and soaked in oil vaseline; the strips should be 
introduced in layers, in order to avoid injurious bunching, and also to 
hold the flaps in place. 

Hematoma of the septum does not occur when coaptation of the 
mucoperiosteal membranes has resulted from the use of suitable dress- 
ings in either method of operating, and perforations are rare if the 
technique is carefully carried out, even in extensive bony resections. 

Remarks. — Some writers have stated that the swivel knife is objection- 
able because it is likely to tear the mucous membrane. Such a statement 
can mean but one of two things, namely : (a) That the operator is extremely 
awkward, or (6) that he fails to elevate the membrane sufficiently. Any 
operator with but a moderate experience with the submucous resection of 
the septum knows that it is almost impossible to tear the mucous mem- 
brane with the swivel knife if the mucoperichondrium is previously 
elevated over the entire operative field. 

One writer makes the claim that the swivel knife is not an exact instru- 
ment — is not under the exact control of the operator. This is a mistaken 
idea, and is not based upon personal experience, but is a theoretical 
deduction. As a matter of fact, it is one of the most exact and easily 
controlled instruments used in this operation. It cuts cartilage with 
but slight resistance, and may be directed with the greatest precision, 
so as to encircle the amount of cartilage it is necessary to remove. 

Authors differ as to the reformation of the cartilage of the septum 
after its removal. According to J. C. Beck (Figs. 88 and 89), no cartilage 
cells were found in the tissue after a lapse of two and one-half years. 



102 



THE XOSE AND ACCESSORY SINUSES 



The removed cartilage was replaced by dense fibrous tissue. Freer, on the 
other hand, claims that the cartilage reforms, especially in the younger 
subjects. 



Fig. 88 




Section of septum two and one-half years after a submucous resection of bone and cartilage 
shows no regeneration of either bone or cartilate, but is replaced by a dense fibrous tissue. Age, 
forty-seven years. (Specimen kindly loaned by Dr. J. C. Beck.) 



Fig. 89 




Same as Fig. 88. with higher power. 



PERFORATION OF THE SEPTUM 1()3 



PERFORATION OF THE SEPTUM 

Etiology. — Ther causes of perforation of the septum may be divided 
into (a) congenital, (b) chronic granuloma, (c) traumatic, (d) acute 
infection, and (e) atrophic or perforating ulcer. 

(a) Congenital perforation is extremely rare, Zuckerkandl having 
reported a few cases. 

(b) Chronic granulomata — as syphilis, tubercle, and lupus — have 
caused a considerable percentage of the cases, some authors attributing 
as high as 50 to 60 per cent, to syphilis alone. In my experience the 
percentage due to syphilis is much less than this; syphilis is not, however, 
as common in this as in some other countries. Syphilitic perforations 
almost always include the bony portion of the septum, whereas, tubercle 
and lupus are limited to the cartilaginous portion. The tuberculous 
and lupous origin of the perforating ulcer may be determined by finding 
the tubercle bacilli, or tuberculous histological changes in the tissues. 
A slow but reliable method of demonstrating the tuberculous process is 
to inject a guinea-pig with some of the tissue from the ulcer. Six weeks 
later hold a postmortem on the pig and note the presence or absence 
of a tuberculous process. 

(c) Traumatic perforations may include any portion of the septum, 
as they are usually due to surgical procedures, though they may be due 
to accidental violence and to picking the nose with the finger nail. 

(d) Acute infectious diseases, as diphtheria, scarlet fever, typhoid 
fever, phlegmonous abscess, etc., may result in perforations. 

(e) Atrophic or perforating ulcer of the septum is probably the most 
common type of perforation. Several conditions contribute to the 
etiology of this type of perforating ulcer. An anterior spur or deviation 
of the cartilaginous portion of the septum is usually present, and on 
account of its projection into the field of the inspiratory current of air, 
it is subjected to constant mechanical irritation and to the desiccation 
of the secretions which constantly accumulate upon it. The ciliated 
columnar epithelium undergoes retrograde changes to a less specialized 
type of epithelium (pavement epithelium). The dust and other foreign 
substances in the air also irritate the epithelium and mucous membrane. 

The crusts thus formed in this area become adherent, and are forcibly 
blown or picked off with the finger nail, the epithelium coming away 
with them. Hemorrhagic deposits in the mucous membrane occur, and 
epistaxis is of frequent occurrence. The retrograde process continues 
until the entire thickness of the septum is destroyed. Infection plays 
a part in the foregoing process. 

Symptoms. — The symptoms of perforation of the septum vary with 
the size, cause, and location of the perforation. A small anterior per- 
foration, sometimes gives rise to a musical, whistling sound, whereas, a 
large one does not. If the perforation is associated with a prominent 
bony spur, there may be a sense of stuffiness in the nose. Crusts, if of 
large size, may give rise to the feeling of a foreign body in the nose, and, 



104 THE NOSE AND ACCESSORY SINUSES 

if forcibly blown or picked off, may cause nasal hemorrhage. Repeated 
epistaxis should arouse suspicion of a perforating ulcer. Syphilitic ulcer- 
ation is usually accompanied by an offensive necrotic odor. Many cases 
will progress to complete perforation without the patient's knowledge 
of the fact. 

Treatment. — If seen in the ulcerative stage, before perforation, the 
progress of the local retrograde changes may be checked by appropriate 
local cleansing and antiseptic washes and ointments, or, if due to syphilis, 
by the administration of the proper remedies for this disease. When 
the perforation is complete, little can be done except in a surgical way. 
Large perforations are not, however, amenable to surgical closure. 
Small ones may often be closed by proper plastic surgical procedures. 

Fig. 90 




The edge of the cartilage around the perforation (c) being removed with the author's 
single-tined swivel knife in Goldstein's plastic septum operation. 

Goldstein's Plastic Flap Operation.— Dr. M. A. Goldstein has suggested 
and successfully used the following operation. A plastic flap of mucous 
membrane is turned into the opening and inserted and sutured between 
the elevated membranes of the two sides of the septum. 

Technique. — (a) Cocaine anesthesia. 

(b) The rim or edge of the perforation is freshened by paring off the 
epithelium and mucous membrane. 

(c) The mucoperichondrium is then elevated for a distance of 
one-half inch around the edge of the perforation. 

(d) A ring of cartilage is then resected for one-eighth to one-fourth 
inch from the edge of the perforation, the author's single-tined swivel 
knife being used for the purpose (Fig. 90). 



PERFORATION OF THE SEPTUM 



105 



(e) A mucous membrane flap, the area of which is considerably larger 
than the perforation, is then dissected from the most convenient 
surface of the septum and turned into the perforation and tucked 
between the elevated membranes around the perforation. I have 
devised a trailing swivel knife (Fig. 91) for outlining this flap. The 
method of using it is shown in Fig. 92. 



Fig. 91 




The author's mucosa swivel knife. 



(/) When the pedicled flap is in position (Fig. 93), three or four 
Yankauer stitches hold it in position. One surface is covered by 
epithelium, while the other is left to heal by granulation from the 
edges of the closed perforation. 



Fig. 92 



Fig. 93 





%*4,' 



Showing the method of outlining the flap with 
the author's swivel mucosa knife for the closure 
of a perforation of the septum. 



f, the piastic flap sutured in the perfora- 
tion; c. the pedicle of the plastic flap; 6, the 
denuded area from which the plastic flap is 
removed heals by granulation; d, the edge 
of the plastic flap between the mucoperi- 
chondria of the septum. 



Hazletine's Plastic Operation. — This operation is also only suited to 
small perforations. It is more simple than the pedicled flap operation, 
and appears to be a more satisfactory procedure. 



106 



THE NOSE AND ACCESSORY SINUSES 



Technique. — (a) Cocaine anesthesia. 

(6) Freshen the edges of the perforation and elevate the mucoperi- 
chondrium, as in the submucous resection operation. 

(c) Make a long curved incision (Fig. 94, b, b) through the muco- 
perichondrium, one-fourth to one-half inch anterior to the perforation, 
and elevate the ribbon-flap thus made. 



Fig. 94 



Fig. 95 





Schema of Hazleune's plastic operation 
for the closure of perforations of the septum : 
b, b, incision in front of the perforation; e, e, 
the incision posterior to the perforation on 
the opposite side of the septum; c, c, the 
freshened edges of the perforation. 



Detail of Fig. 94, showing the opposite 
side of the septum, the flap formerly cov- 
ering area a is sutured to the posterior 
margin of the perforation. 



(d) Make a long curved incision (e, e) through the mueoperiehondrium 
of the opposite side of the septum, one-fourth to one-half inch posterior 
to the perforation, and elevate the flap. 



Fig. 96 




Detail of Fig. 94. a, the denuded cartilage after the plastic flap {d, d) is sutured. 

(e) Suture the anterior flap to the freshened posterior edge of the 
mucous membrane of the perforation (Fig. 95), and the posterior flap 
on the opposite side of the septum to the freshened anterior edge of 
the membrane of the perforation, as shown in Fig. 96. The areas 
a and a heal bv granulation. 



PERFORATION OF THE SEPTUM 



107 



(J) Remove the sutures in twenty-four to thirty-six hours. By this 
procedure the perforation is covered by two mucous membranes, and, 
the lines of suture not being opposite, closure of the perforation follows. 

Yankauer's Intranasal Suture. — Sydney Yankauer has devised instru- 
ments for intranasal suturing which may be applied in repairing rents 
in the mucous membrane of the septum following the submucous 
resection operation, in closing the mucous membrane wound of the 
inferior turbinate after resecting the hvpertrophied membrane and 
bone, and in the plastic operations upon the septum for the closure of 
chronic perforations. The technique is as follows: 



Fig, 97 




Yankauer's intranasal suture: A, A, A. the suture thread, being drawn forward with the hook. 
The needle is then reversed and withdrawn from the nose, rethreaded, and another stitch taken in 
the torn mucous membrane. 



The Introduction of the Suture. — Catgut suture eighteen inches in 
length should be used. It should be placed in a carbolic solution for a 
few moments to soften it. The suture may be passed through either 
flap, preferably through the more movable one. It should then be 
passed through the other flap after first coapting the two flaps. If 
necessary, the crotch forceps may be used to facilitate the penetration 
of the flaps with the needle. 

Grasping the Thread. — The eye of the needle should project only one- 
eighth of an inch through the membranes. One of the threads should 
then be seized with the hook, which may be rotated with the pilot wheel 
at the end of the instrument until it is in position to seize the thread. 

Withdrawing the Needle. — When the thread is in the grasp of the 
hook, the needle should be removed from the flaps by rotating it back- 



108 



THE NOSE AND ACCESSORY SINUSES 



ward until it is free from the membranes. It should then be with- 
drawn from the nose. The hook should in the meantime be kept close 
to the needle puncture to prevent the thread from tearing out. 

Withdrawing the Hook. — The hook is then withdrawn from the nose 
with the loop of thread. One side of the loop is then drawn from the 
nose ready for making the slip-knot. 

Making the Slip-knot. — First see that both ends of the thread are 
outside of the nose, and that they are not entangled. To make the 
slip-knot, have one end include half of the thread (nine inches) outside 



Fig. 98 



Fig. 99 





The slip-knot. 



Yankauer's intranasal suture method of conveying 
the knot into position in the nasal chamber. 



of the nose, the other end being correspondingly shorter. Then make 
a simple overhand knot near the middle of the long ends, and pass the 
shorter end through the bight of the knot, as shown in Fig. 98. Tighten 
the slip-knot until it binds the through thread. Two threads now 
come through the knot, one the knot end, the other the slip end. 

Closing the Slip-knot —The slip-knot being drawn tight over the 
thread, it is brought near the nostril. The knot end of the thread is 
passed through the ring of the suture closer until the ring is near the 
knot. The end of the thread is then held with the thumb against the 



PERFORATION OF THE SEPTUM 109 

handle of the instrument, as shown in Fig. 99. The left hand holds 
the slip end, and the ring suture closer is advanced into the nose and 
the knot closed where the suture passes through the mucous membrane. 
The ring passes beyond the point where the suture passes through the 
membranes, and thus makes as firm a knot as may be desired. 

The remaining portion of the wound may be closed by making a 
continuous suture with the longer end of the thread, only using the 
slip-knot for the last stitch to fix it in place. If preferred for any reason, 
each stitch may be made separately as above described, cutting off the 
ends as in external suturing. 

The sutures should be removed in from two to three days. 

The Safety Knots. — In order to prevent the slip-knot from becoming 
loose, it is advisable to make a true surgical knot, consisting of two 
overhand knots, above the slip-knot. 

Goldsmith's Operation. — When both mucoperichondria are torn during 
a submucous operation, thus making it probable that a permanent 
perforation will follow, the cartilage removed may be reintroduced 
between the membranes, and thus afford a bridge over which the granu- 
lating edges of the mucous membranes may extend and close the 
perforation. 

Technique. — (a) When the cartilage is removed with the swivel knife 
during the submucous resection operation, it should be placed in normal 
salt solution to preserve it for use in case the mucous membranes are 
torn. The cartilage may be thus preserved for about six weeks in cold 
weather. 

(b) If the cartilage is misshapen, it may be straightened or trimmed 
to adapt it to the requirements of the case. 

(c) It should then be introduced between the membranes, care being 
exercised to bring the torn and ragged edges of the membranes well 
over the cartilage on both sides. 

(d) A Simpson-Berney sponge-tent splint should then be introduced 
into each nasal chamber to hold the cartilage and membranes in posi- 
tion. The sponge-tents should then be moistened with sterile water to 
swell them. (See Fig. 86.) 

(e) The tampons should be removed on the third day. 

By the end of this time the granulations will have extended well 
over the cartilage and in a few more days will have covered it. In 
this way the perforation is bridged with new mucous membrane. The 
cartilage is gradually absorbed, leaving a membranous septum at this 
point. 

Cartilage may also be used to close old perforations. The edges of 
the perforation should first be pared, the membranes separated around 
the circumference of the perforation, some cartilage removed, and the 
foreign cartilage introduced and retained in position, as in Goldsmith's 
procedure for rents and tears during the submucous operation. 



CHAPTER VI 

THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE 
AND ACCESSORY SINUSES 

INFLAMMATION 

Acute Inflammation. — Acute inflammation is a threefold reaction 
excited by the presence of certain noxa, or irritant material, in the tissues. 
The noxa or irritant is usually a pathogenic microorganism and its 
toxin, or it may be of chemical or traumatic origin. When of chemical 
or traumatic origin the irritant primarily consists of the dead or broken- 
down cells of the tissues. 

Dead or broken-down cells, when present in the tissues in excess, be- 
come foreign bodies, and, as such, a reaction of the living cells is excited 
for the purpose of eliminating them from the body. Furthermore, the 
dead cells in the process of disintegration give off a ferment or chemical 
substance which also excites a reaction, the purpose of which is to free 
the tissues of its presence. The reaction thus far excited is directly 
traceable to the presence of dead and disintegrating tissue cells. Or- 
dinarily, after a short time, a secondary irritant gains entrance to the 
injured tissues and becomes the more important factor in the reactionary 
process. That is, pathogenic bacteria infect the impaired tissues so 
that in nearly every acute inflammatory process, whether it is due to 
primary infection or to chemical or mechanical trauma, pathogenic 
microorganisms must be regarded as the paramount exciting or noxious 
agent causing the reaction of inflammation. 

The reaction of inflammation is, therefore, an increased physiological 
activity of the living tissues of the body for the purpose of disposing of a 
noxious or irritant substance or organism that has invaded them in 
excess of the normal quantities. 

The reaction of acute inflammation is a threefold process, namely: 

1. Increased hyperemia. 

2. Increased nutrition (increased resistance). 

3. Increased leukocytosis. 

1. Increased hyperemia is a constant and important reaction, as 
through it the cells are provided with the extra nutrition they need 
under conditions of stress. The increased blood supply also stimulates 
and facilitates the increased migration of leukocytes, and it flushes the 
poisoned area and dilutes the noxious substance, and thus reduces the 
intensity of the irritation. The hyperemia is nearly always passive 
in type. 

2. Increased nutrition of the cells is promoted by the hvperemia, 
(110) 



INFLAMMATION 111 

for obvious reasons. They are under stress because of the presence of 
noxious substances, and need extra nutritional facilities. Their vital 
force, or resistance, is not equal to the emergency placed upon them, 
and upon their resistance depends the issue of the warfare. Their means 
of defense may be characterized as twofold, namely: (a) their ability 
to envelop and digest microorganisms, and (b) their ability to produce 
and emit a biochemical substance or ferment, the purpose of which is 
to weaken or destroy their foe. All this requires increased nutrition 
(blood), which begets increased powers of resistance. If the nutrition is 
not adequate for these purposes, the microorganisms and their toxin, or 
biochemical irritant, may cause destructive and what we are accustomed 
to call pathological changes in the tissues. 

3. Increased leukocytosis is also an important reaction of inflam- 
mation. While the function and modes of activity of the keukocytes is 
not fully understood, it has been fairly well demonstrated that the 
polymorphonuclear leukocytes envelop and destroy bacteria, while the 
lymphocytes envelop and destroy broken-down cells. Other cells, as the 
fibroblasts, also participate in these functions under certain conditions. 

Quality of Reaction. — Parenthetically, I wish to add one additional 
statement concerning the adequacy of the reaction of inflammation. 
According to Adami, the reaction of inflammation may be of three types: 

1. Adequate reaction. 

2. Inadequate reaction. 

3. Excessive reaction 

The reaction is usually inadequate; that is, the increased hyperemia, 
cell nutrition, and migration of leukocytes is insufficient to dispose of 
the pathogenic microorganisms and their toxins before they have caused 
considerable damage to the tissues. It follows therefore, that in the 
treatment of inflammatory diseases the reaction of inflammation should 
be promoted rather than diminished. By so aiding the defensive 
and offensive activities of the tissues, the bacteria, their toxins, and the 
broken-down tissue cells may be speedily removed and a cure effected. 

Inflammation Affecting Mucous Surfaces. — According to Adami, the 
main distinguishing feature of the mucous surface is the presence of a 
layer of mucous cells of a glandular type, capable, when stimulated, 
of forming and discharging relatively large amounts of mucin. The 
hyperemia, the exudation of serum, the migration of leukocytes, occur 
in the submucous layer just as in the subserous layers. The changes 
in the reaction are due solely to the interposition of this layer of mucous 
cells. There is, in the first place, a more definite basement substance 
interposing a certain amount of resistance to surface exudation. The 
layer of mucous cells is more complicated, and although the fully devel- 
oped cells may be discharged, they are apt to remain relatively undiffer- 
entiated "mother cells" at the base; or otherwise the same intensity 
of irritation does not lead to as extensive a denudation. And, thirdly, 
by the combined action, it may be, of the irritant and of the hyperemia, 
the fully formed mucous cells are stimulated to produce increased 
amounts of mucin, so that an inflammation of moderate grade is char- 



112 THE NOSE AND ACCESSORY SINUSES 

acterized by an abundant amount of mucinous discharge rather than of 
fibrinous deposit. 

Adami speaks of such a moderate case, with exudation of serum 
containing abundant mucin, cast-off mucous cells, and relatively few 
leukocytes, as a "catarrhal inflammation;" if sufficient leukocytes are 
extruded the character is altered to that of a "mucopurulent inflamma- 
tion;" if more severe, with complete destruction of the mucous membrane 
proper, then, as in serous surfaces, there is the same tendency for the 
leukocytic exudation to favor a deposit of fibrin upon the surface, and 
then we obtain a "membranous inflammation." 

He says that despite the fact familiar to all that diphtheria is a disease 
set up by a specific bacillus, and the equally well-known fact that a like 
membranous inflammation may be induced by several forms of microbes, 
we still commonly speak of such a membrane as being diphtheritic. It 
would be better to confine this term purely to cases in which we know that 
the bacillus diphtheria is the causative factor; failing this, we may accept 
the term diphtheritic as covering all such membranous inflammation, 
and employ the term diphtherial for such cases as are of pure diphtherial 
origin. 

If there is a more severe destruction of the superficial cells, ulceration 
mav occur. When pyogenic organisms are present, there is a dissolution 
and breaking down of any fibrin that is formed and a consequent absence 
of a membrane. In such cases there is a distinct tendency for the process 
to extend in the submucosa beneath the still intact mucous membrane, 
the part becoming infiltrated with pus, forming what is known as 
phlegmonous inflammation. 

Chronic Inflammation. — The reaction of chronic inflammation con- 
sists of the ^following phenomena: 

(a) Slightly increased hyperemia. 

(b) Slightly increased cell nutrition. 

(c) Slightly increased migration of leukocytes. 

It is needless to add that the reaction is inadequate to remove the 
noxa or irritants, which, according to pathologists, are usually bacteria 
of low virulence. 

A product of chronic inflammation that is always present is the pro- 
liferation of fixed cells, usually of the least differentiated type, namely, 
connective-tissue cells. (See Hyperplastic Rhinitis.) 

Etiology. — Having thus briefly defined inflammation, we are prepared 
to discuss its causes. 

The causes of inflammatory diseases of the nose and accessory sinuses 
are divided into two groups, namely: 

1. Exciting causes. 

2. Predisposing causes. 

1. Exciting Causes. — The exciting causes are bacteria and chemical 
and traumatic destruction of tissue cells. This phase of the subject 
has already been discussed under Inflammation, and will not be dwelt 
upon in this connection further than to say that pathogenic bacteria 
cannot irritate the tissues of the body so long as the resistance of the cells 



INFLAMMATION 1 13 

is normal ; that is, so long as they are healthy. There may be an exception 
to this rule when the germs are exceptionally virulent, though this is 
rare. Virulent pathogenic bacteria are constantly present in the upper 
respiratory tract, though they are harmless until the resistance of the 
cells is lowered by some intracorporeal or extracorporeal influence. 

2. Predisposing Causes. — There are many predisposing causes of 
inflammatory diseases of the nose, some of which are best explained by 
grouping them around a well-recognized physiopathological law, namely: 
When the drainage and ventilation of a mucous membrane-lined cavity is 
impaired or blocked, the conditions are favorable for the growth of patho- 
genic bacteria. 

If this is true, each case of inflammatory disease of the nose and acces- 
sory sinuses should be examined to ascertain if the drainage and ventila- 
tion of these spaces are impaired or blocked. If they are, the obvious 
therapeutic duty is to remove the obstruction by such remedial measures 
as will best accomplish the purpose. These measures may be either 
medicinal, hygienic, or surgical. 

If, on the contrary, no obstructive lesion is found, other causes for the 
lowered resistance of the tissue should be sought for. If the inflamma- 
tion is a primary acute one and the lowered resistance is due to shock 
from exposure, it may be useless to attempt to remove the cause, as it is 
transient. The immediate duty in such a case is to promote the reaction 
of inflammation and thus check the inflammatory process. As Adami 
so aptly says, the way to cure inflammation is to increase it. 

In order to logically approach the consideration of the causes of the 
lowered resistance of the mucous membrane of the nose and accessory 
sinuses, they should be divided into two groups, namely: 

(a) Extranasal. 

(b) Intranasal. 

Extranasal Predisposing Causes. — Age seems to exert some influence 
upon the resistance of the nasal mucous membrane. Young children 
and young adults are more frequently subject to inflammatory diseases 
of the nose and accessory sinuses than those of more advanced years. 
This is, no doubt, due in part to indiscretion, as improper habits, and 
insufficient protection of the body from the inclemencies of the weather. 
Persons of more mature years have more mature minds and better 
judgment and do not expose themselves needlessly, as in youth and 
childhood. Then, too, the tissues acquire resistance, or immunity to 
the noxious irritations. 

Sex, perhaps, exerts some influence on the occurrence of inflammatory 
processes. Males are more exposed and more reckless than females, 
hence they are more often affected by inflammatory diseases. They are 
more pugilistic, and often have broken noses and consequent nasal 
obstruction. 

Climate undoubtedly influences the occurrence of inflammatory pro- 
cesses. In regions where there is much cold, wet weather with sudden 
changes of temperature and of hygroscopic conditions of the atmosphere. 
it is more difficult to protect the body, particularly the feet, from the 



114 THE NOSE AND ACCESSORY SINUSES 

shock incident to such exposures. The shock thus sustained by the vaso- 
motor nervous system leads to a lowered resistance of the mucous mem- 
branes, especially of the nose and accessory sinuses, hence the growth 
of bacteria in these regions is favored. 

Exposure, especially unusual or unequal exposure of the body to damp, 
cold, or other atmospheric and metallurgic conditions, weakens the 
resistance of the tissues. The exposure of the feet to damp and cold is 
a most fruitful source of rhinitis and inflammations elsewhere in the 
body. Draughts striking a single portion of the body are detrimental 
to the resistance of the tissues much more than when the whole body 
is thus exposed. Within certain limitations the exposure of the whole 
bodv often has a tonic effect, as all the animal mechanisms of the body 
are equally and simultaneously stimulated. When partial exposure is 
experienced, only a portion of the mechanism is stimulated, and an 
imbalance of the functional processes results; that is, there is confusion 
and havoc in the cellular activities, the nasal expression of which is 
often some form of inflammation. 

Clothing is an important factor in maintaining or lowering the 
resistance of the mucous membranes of the upper respiratory tract. 
Too much is as productive of evil as too little clothing. If too much is 
worn, the skin is rendered sensitive to slight exposure, and if too little, 
the body is subjected to continual stress, and exhaustion of the vital 
forces results. Either condition prepares the soil for the growth of 
pathogenic bacteria in the respiratory passages. Perhaps the most 
vulnerable part of the body is the feet, through the soles of which 
course large bloodvessels. Cold or wet feet is a common cause of 
acute rhinitis and sinuitis. 

The proper selection of underwear is a much mooted question. Wool 
is advocated by some, while linen or linen mesh is strenuously recom- 
mended by others. At the present time, most persons buy cotton for 
summer and cotton and woollen mixtures for winter wear; not because 
they believe they are the best, but because they are cheaper. My 
ideas on the subject are as follows: 

Linen absorbs moisture better than either cotton or wool, and is, 
therefore, better for summer wear. Wool is warmer than either cotton 
or cotton and wool, and is better for winter wear. Those who perspire 
easily in winter should wear linen next to the skin. If this does not 
retain enough body heat, light wool should be worn over the linen 
underwear. Cotton or cotton and woollen mixtures are perhaps never 
preferable to wool and linen, and woollen underwear during the winter 
months. Silk is warm, absorbs perspiration, and is non-irritating to 
the skin. For persons with sensitive skins, it is, therefore, the ideal 
material for winter undergarments. 

Undergarments should be of medium weight for the winter months, 
the overgarments being depended upon for extra protection for outdoor 
wear. If the indoor clothing is too heavy the skin becomes tender and 
subjects the wearer to shock upon undue exposure when out of doors. 

The underclothing and outergarments should, therefore, be selected 



INFLAMMATION 115 

for their absorptive, non-irritating, and heat-retaining properties. Hard- 
and-fast rules cannot be laid down with reference to clothing, as every 
individual is a law unto himself. The aim should be to so regulate the 
clothing as to avoid either extreme, since to do otherwise subjects the 
system to shock, and thus lowers the cellular resistance, and prepares 
the soil for the growth of microorganisms and inflammation. 

The digestive tract is regarded by Woakes and Stucky as contributory 
to inflammatory processes of the upper respiratory tract. In this they are 
correct. If the processes of digestion and nutrition are imperfectly per- 
formed, noxious material enters the vascular lymphatic circulation and 
thus places unusual stress upon all the fixed and migratory cells of the 
body. Lowered resistance, therefore, naturally follows. 

Certain constitutional diseases likewise produce a lowered resistance 
of the tissues, including the mucous membranes of the nose, accessory 
sinuses, and ears. Diabetes, syphilis, and all, diseases due to faulty 
metabolism especially affect the tissues of the respiratory tract, and 
predispose them to infection and inflammation. 

Heredity probably has no direct influence in the predisposition to 
infectious and inflammatory diseases of the nose. Indirectly it may have 
such an influence. That is, certain anatomical conformations of the 
nasal chambers may be transmitted from parents to the child and thus 
establish a predisposition to infection and inflammation. 

Adenoids may interfere with the drainage and ventilation of the nose 
and accessory sinuses, or inflammation focalized in them may lower the 
resistance of the mucous membranes of the nasal and accessory sinuses, 
and thus predispose to infection and inflammation. These and other 
extranasal influences may prepare the soil for the growth of pathogenic 
bacteria in the nose and accessory sinuses and result in inflammation of 
the sinuses without obstructive lesions in the nose. Whatever the cause 
of the lowered resistance of the mucous membrane, the result is the same. 

I do not wish to be understood as saying that infection and inflamma- 
tion always follow a lowered resistance of the nasal mucous membrane. 
I only claim that a lowered resistance predisposes to such a process. The 
virulence of the microorganisms and other conditions enter into the 
equation. 

Intranasal Predisposing Causes. — I wish to repeat the physiopathological 
law which largely explains the occurrence of infection and inflammation 
of the nose and accessory sinuses, namely: Cavities lined with mucous 
membrane are predisposed to inflammation when their drainage and 
ventilation are obstructed. 

We know that when such obstructions have been present and are 
removed, either by local applications or by surgical interference, relief 
often promptly follows. 

Let us direct our attention, therefore, to some of the obstructive 
lesions of the nose which predispose the mucous membrane to infection 
and inflammation. 

Obstruction of the Lower Portion of the Nose. — I desire to first call 
attention to a fact that has long impressed me as very important, namely, 



116 THE NOSE AND ACCESSORY SINUSES 

that obstructions in the lower portion of the nasal cavity have a different 
clinical significance than those located higher in the nasal passages. I 
also wish to call attention to the clinical significance of anterior obstruc- 
tions as contrasted with obstructions otherwise located. 

Obstruction of the inferior portion of the nasal passage causes an 
approximation or an impingement of the inferior turbinal against the 
septum at certain points. The pressure may be either intermittent 
or constant, The question of greatest importance is, How does such 
an obstruction affect the drainage and ventilation of the nose and 
sinuses? As most of the mucous membrane of the nose and sinuses is 
located above the inferior turbinal, it is obvious that ventilation is but 
little affected by such an obstruction. The pathway of the inspiratory 
current is largely limited to the middle and superior meatuses of the nose, 
and, inasmuch as an obstruction located inferiorly does not materially 
occlude the inspiratory tract, there is comparatively little disturbance 
of function. Furthermore, the drainage of the secretions is not materially 
blocked. The usual obstructive lesion in this region is a spur or ridge 
on the septum. The ridge is rarely equally prominent along its entire 
length. On the contrary, it presents one or two prominent spines or 
knuckles which approximate or impinge against the inferior turbinated 
body, thus leaving wide gaps through which the secretions may drain 
to the floor of the nose without marked impediment, 

The practical deduction to be drawn from these facts is, that an 
obstruction in the lower portion of the nose does not markedly reduce 
the resistance of the mucous membrane, especially in the upper portion 
of the nasal chambers and in the accessory sinuses. It does, however, 
have some influence in this direction, and in a degree predisposes to 
infection and inflammation. The crests of the spines or knuckles 
may accumulate secretions, which become desiccated in the form of 
moist or dry crusts. The tissue cells beneath the crusts are injured 
and their resistance lowered, and to this extent there is a predisposition 
to infection and inflammation. Furthermore, the impingement of the 
spur or ridge against the outer wall of the nose causes traumatic injury 
and results in some degree of lowered resistance, which may lead to 
bacterial infection and inflammation. 

Obstructive lesions in the lower portion of the nose, therefore, may 
cause a turgescence of the mucous membrane, which is richly supplied 
with erectile tissue (the "swell bodies"), which after a more or less pro- 
longed period may result in hypertrophy. In the early or turgescent 
stage the condition is called turgescent rhinitis; in the later stage it is 
called hypertrophic rhinitis. If, however, repeated infection occurs, the 
irritation is of a different type and causes hyperplastic changes. 

Unfortunately, however, a deviation of the lower portion of the septum 
is usually accompanied by a deviation of the upper portion in the region 
of the middle turbinal. When this is the case the type of inflammation 
is radically different from that present in an uncomplicated low^er 
deviation. That is, a deviation in the region of the middle turbinate 
often obstructs the drainage and ventilation of the superior meatus and 



INFLAMMATION H7 

of all, or nearly all, of the nasal accessory sinuses. The secretions are 
retained, undergo decomposition, liberate a ferment, and irritate the 
mucous membranes. In brief, the inflammation is attended by the pro- 
liferation of the least differentiated of the fixed cells or connective-tissue 
cells. In other words, hyperplasia of the mucous membrane occurs. 
This is known as hyperplastic rhinitis. The irritation in the middle 
turbinal region may extend by continuity of tissue to the inferior turbinate 
and cause hyperplasia of this structure as well. Hence, hyperplastic 
rhinitis often involves both turbinated bodies. In simple deviations, 
however, limited to the lower portion of the nasal chambers, the inflam- 
mation is usually of the hypertrophic type. 

Obstruction of the Anterior Portion of the Nose. — Deviation of the 
anterior portion of the septum from traumatism is a common cause of 
obstruction of the anterior portion of the nasal chamber. The relation- 
ship it bears to inflammatory processes of the nose and accessory sinuses 
is interesting and instructive. An anterior deviation does not interfere 
with the drainage of the secretions except in so far as it may interfere with 
the mechanical force of the respiratory currents of air. The mechanical 
force of the inspired air is especially manifested in the region of the infun- 
dibulum and posterior ethmoidal cells where the inspiratory current 
sweeps over the hiatus semilunaris and the ostei of the posterior ethmoidal 
cells and causes slight rarefaction of the air within the sinuses drained 
by these openings. The mechanical impact facilitates the flow of 
secretions from the ostei and hiatus semilunaris, and thus prevents 
desiccation and stoppage of these openings. To this extent obstructive 
anterior deviations of the septum interfere with drainage. 

The ventilation upon the obstructed side, however, is very materially 
affected. The slight interference with the flow of the secretions caused by 
the absence of the mechanical impact of air results in a moderate reten- 
tion of secretions. Decomposition of the secretions may, therefore, take 
place and cause a lowered resistance of the mucous membrane, and thus 
establish a predisposition to infection and inflammation. 

When the ridge or spur in the lower portion of the nose extends well 
forward into the vestibule, it also interferes with the ventilation and 
drainage, as described in the preceding paragraph. 

When either type of anterior obstructive deviation is present, another 
and more important etiological factor must be taken into consideration, 
namely, the rarefaction of air posterior to the obstruction. Air being- 
unable to enter the nostrils rapidly enough during the descent of the 
diaphragm is rarefied, or a state of negative air pressure is established. 
This, according to Bier's theory, should prevent serious inflammatory 
processes, as the negative air pressure thus produced promotes the reac- 
tion of inflammation and should prevent serious inflammatory disease. 
Doubtless the negative pressure thus automatically produced does exert 
a favorable influence upon the inflammatory process excited by the lack 
of ventilation and the slight retention of the secretions. Thus, strange 
as it may seem, the anterior obstructive lesion predisposes to infection 
and inflammation, and at the same time tends to cure it. 



US THE XOSE AXD ACCESSORY SINUSES 

Clinically, I have often noted the comparatively slight inflammatory 
disease of the nasal mucous membranes which is present in cases of 
simple anterior deviations. 

The chief departure from the normal is a turgescence or an hypertrophy 
of the inferior turbinates. Little pathological change is present in the 
middle turbinate region unless there is an associated obstruction in 
that location. The negative air pressure easily accounts for the turges- 
cence of the erectile tissue of the inferior turbinates. After a prolonged 
duration of the turgescence, whether intermittent, alternating, or con- 
stant, hypertrophy occurs as a result of the increased nutrition. 

Obstruction in the Middle Turbinal Region. — Obstruction in this por- 
tion of the nasal chambers is productive of more serious inflammatory 
disease of the nose and accessory sinuses than obstruction in any other 
portion of the nose. The reason is obvious when we recall the fact that 
the ostei of the posterior ethmoidal and sphenoidal sinuses drains into the 
superior meatus above the middle turbinate, while the frontal, anterior 
ethmoidal, and maxillary sinuses drain into the middle meatus beneath 
the middle turbinate. 

If the septum is deviated so as to press against or approximate near 
to the middle turbinate, the olfactory fissure is blocked and the drainage 
of the posterior ethmoidal, and possibly of the sphenoidal, cells is inter- 
fered with. 

Clinically, I have noted the presence of two types of deviations of the 
septum that close, or nearly close, the olfactory fissure. One is a bowing 
of the perpendicular plate of the ethmoid bone and quadrilateral cartilage, 
and the other is a thickening of the septum in the region of the middle 
turbinated body. The bowed septum is thin and easily corrected by the 
submucous resection of the septum, whereas the thickened septum often 
involves only the mucous membrane and is more difficult to correct. 

In some subjects there are large ethmoidal cells in the middle tur- 
binate, which may either close a part or ail of the olfactory fissure or 
they may encroach upon the hiatus semilunaris beneath it. In the first 
instance the drainage and ventilation of the superior meatus of the nose, 
and in the second instance the drainage and ventilation of the frontal, 
anterior ethmoidal, and maxillary sinuses is impaired. 

A large bulla ethmoidalis projecting medianward and downward may 
obstruct the hiatus semilunaris, and thus obstruct the drainage and 
ventilation of the cells draining into the infundibulum, namely, the 
frontal, anterior ethmoidal, and maxillary sinuses. 

Likewise, the occasional presence of cells in the inner wall of the 
infundibulum, or uncinate process of the ethmoid bone, may block 
the infundibulum and cause serious inflammatory disease of the 
frontal and anterior ethmoidal cells and the maxillary antrum ("vicious 
circle"). 

In about 50 per cent, of the cases the frontonasal canal does not com- 
municate with the infundibulum, but opens directly into the middle 
meatus more anteriorly (Logan Turner). In these subjects an enlarged 
projecting bulla ethmoidalis and cells in the uncinate process would not 



INFLAMMATION 1 19 

block the drainage and ventilation of the cells draining through the 
frontonasal canal, namely, the frontal and anterior ethmoidal cells. 
The ostium of the antrum, however, may be obstructed, as it always 
opens into the infundibulum. 

Results of High Obstructions in the Nose. — When the olfactory fissure 
is obstructed by either septal or turbinal deformity, drainage of the 
secretions and ventilation of the posterior ethmoidal and sphenoidal 
sinuses are impaired. The secretions are retained and undergo retro- 
grade changes. The mucous membrane bathed in the secretions is 
injured and its functional activity and resistance are lowered. The bio- 
chemical substances liberated in the process of decomposition constantly 
irritate the mucous membrane, especially of the middle turbinated 
body. Acute infection occasionally occurs. During the intervals 
between the acute inflammatory processes a mild staphylococcal or other 
infectious inflammation persists. Under these conditions there is a 
proliferation of fixed cells in the tissues, usually the least differentiated 
or connective-tissue cells. 

The result is known as hyperplastic rhinitis, which chiefly involves 
the middle turbinated body and ethmoidal cells, though it may extend 
to the inferior turbinal. 

Obstruction of the Olfactory Fissure. — The partial or complete closure 
of the olfactory fissure and the consequent retention of the secretions of 
the superior meatus, and the ethmoidal and sphenoidal sinuses draining 
into it, cause hyperplastic changes in the mucous membrane, not alone 
of the middle turbinate, but of the superior meatus and of the ethmoidal 
and sphenoidal sinuses opening into it. The conditions thus produced 
favor infection and inflammation. The inflammatory process may be 
either catarrhal, purulent, fibrinous, or phlegmonous in type, and in each 
instance the active causes are pathogenic microorganisms. 

The sinuitis thus excited may continue for years without engaging 
the attention of either the patient or physician. Headache and slight 
dizziness, aggravated upon stooping, may be the only symptoms com- 
plained of, except, possibly, recurrent attacks of acute coryza. Or the 
sinuitis may be distinctly and frankly purulent, with copious discharge 
into the epipharynx, and possibly to some extent through the olfactory 
fissure into the middle meatus. 

Atrophic rhinitis with ozena in adults is, in my opinion, often a result 
of suppurative sinuitis. Space does not permit of a full discussion of 
this phase of the subject. Personally, I have repeatedly overcome the 
ozenic secretion by treating the case as though it were a suppurative 
sinuitis. I have made skiagraphs of several cases of atrophic rhinitis 
with ozena, and without exception they have shown the existence of 
sinus disease. This does not, of course, determine which was primary, 
the atrophic rhinitis or the sinuitis. My opinion is largely based upon 
the results following the treatment for the sinuitis. 

Obstruction Due to the Bulla Ethmoidalis, the Middle Turbinate, and 
Uncinate Cells. — As previously stated, a large bulla ethmoidalis may 
occlude the infundibulum and thus block the drainage and ventilation 



120 THE NOSE AND ACCESSORY SINUSES 

of the maxillary sinus, the frontal and anterior ethmoidal cells. This, 
as heretofore explained, causes the retention of the secretions and 
lowered resistance of the tissue, thus establishing a predisposition to 
infection and inflammation. (See "Vicious Circle" of the Nose.) 

Cells in the middle turbinated body and uncinate process may likewise 
block the infundibulum and cause similar results. The exception has 
been referred to wherein the frontonasal canal opens directly into the 
middle meatus anterior to the infundibulum. 

It appears, therefore, that there are several factors entering into the 
causation of inflammatory diseases of the nose and accessory sinuses. 
The exciting causes are nearly always pathogenic microorganisms, while 
the predisposing causes are numerous extranasal influences which are 
often combined with obstructive lesions in the nose. The latter should 
always be studied with reference to whether they interfere with the 
drainage and ventilation of the nose and accessory sinuses. If only 
extranasal causes of lowered resistance are found, the treatment should 
be addressed to their removal; and if in addition to the extranasal 
influences obstructive lesions are discovered, they should be corrected by 
probing or by surgical interference. 

Conclusions. — 1. Acute inflammation is usually a threefold reaction 
excited by pathogenic bacteria and their toxins, namely: 

(a) Increased hyperemia. 

(b) Increased nutrition of the tissues. 

(c) Increased migration of leukocytes. 

The reaction of acute inflammation is the response of Nature's forces 
for the purpose of destroying the bacteria and their toxins. 

2. The reaction of inflammation is usually incapable of removing 
quickly the infective bacteria and their toxins, henee>.the inflammation 
continues for several days, or it may be indefinitely prolonged. 

3. Chronic inflammation consists of the same reactions in much less 
degree, and is still further characterized by the proliferation of fixed 
cells into the tissues, notably connective-tissue cells. 

4. The exciting causes of inflammation are pathogenic microorganisms. 

5. Pathogenic bacteria do not per se cause inflammation. There 
must be a lowered resistance of the tissues before they will rapidly 
multiply and produce inflammation. 

6. Anything that lowers the vitality or resistance of the mucous mem- 
brane of the nose and accessory sinuses predisposes it to infection and 
inflammation. 

7. The extranasal influences that lower the vitality of the mucous 
membrane are sex, climate, exposure, improper clothing, digestive 
disorders, constitutional diseases and dyscrasias, hereditary anatomical 
peculiarities of the framework of the nose, adenoids, etc. 

8. The intranasal predisposing causes of inflammation of the mucous 
membrane of the nose and accessory sinuses are, perhaps, best explained 
bv the well-recognized law: Obstruction of the drainage and ventilation 
of mucous membrane-lined cavities predispose them to infection and inflam- 
mation. The character of the inflammation and the final result are 



INFLAMMATION 121 

partially determined by the location of the obstruction in reference to the 
various structures of the nose and to the accessory sinuses. 

9. Anterior and inferior obstructions are the usual cause of turgescent 
and hypertrophic rhinitis. Obstructions in these lesions do not cause 
hyperplastic rhinitis, because they do not materially interfere with the 
drainage of the secretions, and therefore cause little or no irritation. 

10. Obstruction higher in the nose, in the region of the middle turbinate 
and the infundibulum, causes the retention of the secretions and interferes 
with the ventilation of the superior meatus and the accessory sinuses, 
thus lowering the resistance of the tissues and establishing a marked 
predisposition to infection and inflammation of the nasal and accessory 
sinuses. The inflammation may be catarrhal or suppurative, acute or 
chronic in type. 

11. The long-continued mild irritation excited by obstructive lesions 
in the middle turbinal region often results in hyperplastic rhinitis, which 
may be limited to the middle turbinate, though it may extend to the 
inferior turbinate. 

12. Inflammation also extends to adjacent parts by the continuity of 
tissue, hence it may extend from one part of the nasal mucous mem- 
brane to another, or it may extend from the nasal mucous membrane to 
the sinuses, the Eustachian tube, and cavum tympani. 



CHAPTER VII 

THE METHODS FOR PROMOTING THE REACTION OF 
INFLAMMATION 

In the preceding chapter I have shown that acute inflammation 
is a series of reactions excited by the presence of bacteria, their toxins, 
and the cellular debris. The object of the reactions is to rid the tissues 
of these substances. Experience has shown that in acute inflammation 
the reaction is not sufficient to do this as quickly as should be to prevent 
damage to the tissues. That is, necrosis, infiltration, and adhesive pro- 
cesses are likely to occur before the reaction removes these irritants 
from the tissues. It is rational therapy, therefore, to promote the in- 
flammatory reaction rather than to repress it. As a concrete example, 
I will cite acute coryza, or "cold in the head." This is a reaction 
due to certain bacteria and their toxins. It is understood, of course, 
that certain predisposing causes have prepared the soil for the growth 
of the bacteria. Ordinarily, the reaction (increased hyperemia and 
leukocytosis) is inadequate to throw off quickly the bacteria and their 
toxins. The question naturally arises, How to promote and increase the 
reaction? Do not make the common mistake of assuming that the 
inflammatory reaction is already excessive; it may be, but it is usually 
inadequate. Those who assume the reaction to be excessive often apply 
adrenalin locally to reduce the reaction. This reduces the hyperemia, 
cell nutrition, and leukocytosis, whereas they should be increased. 
It does, however, establish better drainage, and to this extent acts 
favorably. 

The same law applies to nearly all acute inflammations of the upper 
respiratory tract, including the ear. It is the purpose of this chapter to 
discuss the various procedures whereby the reaction of inflammation is 
promoted or increased, and to outline the indications and the methods 
for their therapeutic application. 

Counterirritation. — Counterirritation has long been used to counter- 
act inflammatory processes, the prevailing idea being that it diverted 
the blood to the surface and away from the seat of inflammation. We 
know now that while its use was rational, the explanation of its good 
effects was irrational. Counterirritation applied over the inflamed 
area not only increases the superficial hyperemia, but it increases it in 
the deeper tissues as well. It also increases the leukocytosis and cell 
nutrition. Thus, instead of diminishing the inflammation, it promotes 
the inflammatory reaction. 

Counterirritation has but little place in otolaryngological practice for 
(122) 



PROMOTING THE REACTION OF INFLAMMATION 123 

two reasons: (1) Because the blistering and scarring which occasionally 
result are objectionable for cosmetic reasons, and should surgical inter- 
ference become necessary the skin is in bad condition, and (2) because 
more efficacious methods may be employed. 

Poulticing. — This is also an old method of treating inflammation. 
The moist poultice of bread and milk, or other ingredients, is usually 
applied hot, the whole being covered with cloths or oiled silk to retain 
the heat and moisture. While poulticing promotes inflammatory 
reaction, it has fallen into disuse, because better procedures have taken 
its place. 

Scarification and Wet Cupping; Artificial Leeching. — Scarifiers 
were once a part of every family physician's outfit, whereas they are 
now rarely seen. Scarification was usually combined with cupping, and 
was designated "wet cupping." With a comb-like knife or with a 
series of concealed blades liberated^ by pressing a spring, the super- 
ficial layers of the skin were many times incised, and a cup in which 
a few drops of alcohol or a piece of paper was burned was quickly 
applied over the incised surface, and the negative air pressure created by 
the heat in the cup caused free oozing of blood. The idea prevailed 
that this diminished the excessive inflammatory reaction, whereas, as a 
matter of fact, it increased it. That is, it increased the hyperemia 
and leukocytosis, established adequate reaction, and hastened the 
elimination of the bacteria, toxins, and cellular detritus. 

Wet cupping was formerly much practised in cases of acute mastoid- 
itis, and doubtless with beneficial results, though leeching is a much 
better means for relieving the condition. 

Leeching. — This is an old therapeutic measure of great value in 
promoting inflammatory reaction. I have seen children with broncho- 
pneumonia quickly pass from a state of stupefaction, with a pulse of 
200 per minute, to one of complete consciousness, with quiet respiration 
and a pulse of 100 per minute, after the application of a few leeches to 
the chest. Likewise, I have seen the pain and tenderness in acute 
mastoiditis subside under leeching. With the improved technique of 
mastoid surgery, and with the accumulated observations of aural sur- 
geons to the effect that, while many of the cases of acute mastoiditis 
subsided, but few were cured; hence, leeching and kindred measures have 
been gradually abandoned. The keynote to the present-day mastoid 
therapy is the total eradication of the diseased process at the earliest 
possible moment by surgical intervention. Doubtless the pendulum 
has swung too far to the surgical side. An increased knowledge of the 
pathology of inflammation and of the processes of repair will enable the 
surgeon to differentiate more closely between the operative and non- 
operative cases. 

From three to six leeches may be applied over the mastoid process 
and in front of the tragus in the early stages of acute mastoiditis with 
decidedly beneficial effect. This is good treatment while watching 
the development of a case, and in some instances it promotes the 
inflammatory reaction (increased hyperemia and leukocytosis) to such 



124 THE NOSE AND ACCESSORY SINUSES 

a degree as to lead to a speedy recovery. It is doubtful if leeching is 
efficacious after the disease has continued several days. Even then, 
however, it will affect the inflammatory process favorably. The case 
must then be treated surgically (removal of adenoids in children, and 
possibly the exenteration of the ethmoidal sinuses in adults, or a mas- 
toid operation) or it may assume a latent or chronic form. 

Irrigation or Lavage. —This mode of treatment has long been applied 
to inflamed nasal chambers and accessory sinuses of the nose. The 
prevalent idea as to its mode of action is that the solution used 
mechanically removes the inflammatory secretion, and thus lessens the 
noxa or local irritant, all of which is doubtless true. It also increases 
the local hyperemia and migration of leukocytes, i. e., promotes the 
inflammatory reaction. Its action, however, is usually slight and 
transient, and inadequate for the purpose. The inflammatory process 
passes into the chronic type with tissue deposit, thus causing permanent 
changes detrimental to the physiological integrity of the structures. 
There are circumstances, however, under which lavage must be used in 
the treatment of sinuitis. If for any reason operation is refused or is not 
advisable, lavage may be practised through the ostia or through artificial 
openings into the sinuses. In acute cases the reaction thus established 
quickly overcomes the noxa, and healing speedily results. In chronic 
cases the reaction thus promoted is inadequate, and, indeed, in the nature 
of things is not calculated to arrest the noxious process. Chronic 
inflammation consists of hyperemia, slight exudation, slight migration 
of leukocytes, and great tissue proliferation. The last-named process is 
probably not to be checked by any direct means we can employ. 

From the foregoing it is plainly good treatment to employ such solu- 
tions by irrigation as will increase the hyperemia, the migration of 
leukocytes, and the nutrition of the chronically inflamed mucous mem- 
brane. To these ends normal salt, boric acid, mild iodine, and other 
solutions may be employed. It is to be expected, therefore, that while 
lavage will not remove the tissue proliferation, it will promote the 
inflammatory reaction, and in a measure remove the infective noxa 
still remaining. It also removes the irritating toxic secretions, and thus 
relieves the tissues of another source of irritation. 

Massage. — Under this term are included three methods of treat- 
ment, namely: (a) Manual massage, (b) mechanical massage, and (c) 
alternate rarefaction and condensation of air in a cavity, the so-called 
pneumomassage as devised by Delstanche and as modified in the 
various mechanically driven machines so commonly used in America. 

The effect of massage upon inflamed tissue is to increase the hyperemia 
and nutrition, and the diapedesis of leukocytes. The inflammatory 
reaction is thereby promoted and the tissues measurably relieved of the 
irritant noxa. 

(a) Massage of the larynx in acute laryngitis and for the relief of 
singers' nodules has been used with decided benefit. It may be applied 
by hand manipulations or by a vibratory massage machine. The motion 
and physical force thus applied to the exterior of the larynx increases the 



PROMOTING THE REACTION OF INFLAMMATION 125 

hyperemia, nutrition, and leukocytosis of the parts, and thus aids in the 
removal of bacterial infection. 

[b) Mechanical or vibratory massage is of special value in acute 
adenitis of the cervical glands, and its application quickly reduces the 
swelling and tenderness. It is not good treatment, however, to limit 
the attention to this mode of procedure, for to do so is to ignore the 
primary source of the glandular disease, namely, the tonsils, adenoids, 
and pharyngeal glands. The massage is only an adjunct treatment. 

(c) Pneumomassage by means of hand or mechanically driven devices 
has been used extensively and almost empirically for the relief of deaf- 
ness and tinnitus, with but little result. The same procedure applied 
in cases of acute otitis media with an exudative secretion would promote 
the absorption of the exudate and prevent adhesive processes. That 
it has been used for this purpose I am unprepared to say. It is reason- 
able, however, to suppose that the movements thus imparted to the 
membrana tympani and the ossicular chain would increase the hyper- 
emia, the cell nutrition, and the migration of the leukocytes in the 
inflamed mucous membrane, and thus hasten the reparative process. 

Leukodescent Light. — During the past few years radiant energy in 
the form of light from a 500 candle-power incandescent globe has been 
used in the treatment of inflammatory processes (Fig. 100). The benefi- 
cial effects are, perhaps, best explained by saying that this treatment pro- 
motes inflammatory reaction (hyperemia, cell nutrition, and diapedesis 
of leukocytes), and thus hastens the removal of the bacteria and other 
noxious material. I have made use of the light for about five years, 
and have found it one of the most useful, if not the most useful, mechani- 
cal agency for promoting reaction in inflammatory diseases of the upper 
respiratory tract. Acute coryza is sometimes cured under its influence. 
I have repeatedly seen chronic suppurative sinuitis become painless and 
cease to discharge purulent secretions into the nose when this form 
of treatment was used. I have never cured such a case by its use, 
for the purulent discharge reappeared in a few days or weeks after 
discontinuing the treatment. Whether its prolonged use would have 
effected a cure I am not prepared to state. The rays of light relieve 
pain, tenderness, and swelling in an astonishingly short time, and 
superficial infections sometimes disappear rapidly. This is not surprising 
in view of our knowledge of radiant energy from the Finsen light, the 
Rontgen rays, and the high-frequency electrical currents. The 500 
candle-power lamp is known to possess high chemical and penetrating 
properties. In addition to this the heat rays are, of themselves, of great 
usefulness in promoting inflammatory reactions. The combination of 
the chemical and heat rays is ideal in the treatment of inflammatory 
diseases, as the reaction is more profound than that which results 
from either the heat or the chemical rays alone. The range of appli- 
cation of the 500 candle-power lamp is as wide as inflammation itself. 
It will not cure all cases, but if the reaction is inadequate, it will be of 
benefit in so far as it promotes reaction. If the reaction is excessive 
its use is contraindicated, and cold applications should be made. 



126 



THE NOSE AND ACCESSORY SINUSES 



If the reaction is adequate, as in cases of incised wounds which heal 
naturally, its use is contraindicated. It should be remembered that the 
inflammatory reaction usually reaches its maximum of efficiency at the end 
of about twenty-four hours, and that to get the maximum results by any 
of the treatments referred to in this section, they should be applied within 
the first twenty-four hours, before tissue proliferation begins. Tissue 







The leukodescent light should be swung back and forth over the face at a distance of about 
twelve inches for from fifteen to thirty minutes at each treatment . 

proliferation of a permanent type begins at about the fifth day of acute 
inflammation, and becomes more and more established as time goes on. 
The failure of the leukodescent light to cure chronic inflammation 
is explained by the well-known fact that tissue proliferation is a mani- 
festation of chronic inflammation, and that chronic inflammation is not 
readily checked by any direct mechanical means at our command, 



PROMOTING THE REACTION OF INFLAMMATION 127 

except by the most thorough exenteration of all the diseased tissue and 
the establishment of free drainage and ventilation. 

Bier's Treatment. — Bier's treatment has attracted a great deal of 
attention within the last few years. It is based upon the promotion of 
hyperemia in the treatment of acute suppurative, tuberculous, and other 
conditions. He promotes both active and passive hyperemia; active 
by the use of hot air, and passive by constriction of the parts and by 
negative air pressure in cavities. He finds active hyperemia of more 
value in chronic cases, where proliferative tissue is to be absorbed. He 
also finds it useful in acute cases, but not so useful as passive hyperemia 
induced by compression so applied as to obstruct temporarily the efferent 
veins of a part, without arresting the entry of blood through the afferent 
arteries. He also supplies suction by cupping over small inflamed areas, 
and by large glass chambers into which the affected part, as the hand or 
foot, may be introduced and the surrounding air rarefied. 

Sondermann has devised an apparatus especially adapted for pro- 
ducing negative air pressure in the air cavities of the head. Brawley, 
Dabney, and Pynchon have also devised apparatuses for this purpose. 

Bier's treatment is applicable to those cases of acute inflammation in 
which the inflammatory reaction is inadequate to cope with the irritant 
noxa causing the inflammation. The treatment should not be applied 
so as to produce excessive reaction (white edema) of the tissues. It 
should never cause pain. It must not produce paresthesia or false 
sensation. In the nasal chambers it should not be prolonged for more 
than one-half to one hour at a time. The mode of treatment requires 
great caution in its use, as much harm can be done with it. If white 
edema is induced, the bacteria spread through the tissues and the 
process becomes more generalized. 

Inflammation is not yet fully understood, and until it is, cases cannot 
be individualized for treatment. Wright's demonstration of antitropins , 
precipitins, lysins, and opsonins in the blood, and that the opsonins are 
of greater importance than the leukocytes, as the latter are dependent 
upon the former for their efficiency, has disturbed existing ideas to 
such an extent that there is a "shuffling of dry bones" in the scientific 
world. It appears that the leukocytes cannot digest or neutralize the 
bacteria until the latter have been acted upon, weakened, or rendered 
vulnerable by the opsonins. These researches show that Bier's method 
of inducing hyperemia does not simply flush out the inflamed area, but 
that the supply of leukocytes and antitropins causes a rapid removal of 
the dead bacteria from the field of action through the energized leuko- 
cytes (Adami). It appears, therefore, that the opsonic index is of even 
greater importance than the leukocytic index. Should the leukocytosis 
be marked and the opsonins scanty, the bactericidal and scavengerial 
properties of the leukocytes would be greatly impaired, and the reaction, 
while apparently adequate according to the older standard, would be 
inadequate according to the newer standard of the opsinins. However 
this may be, further observations are necessary before the older standard 
is abandoned for clinical purposes. 



128 



THE NOSE AND ACCESSORY SINUSES 



Technique. — In acute inflammatory diseases of the nose and accessory 
sinuses negative air pressure produced by the Sondermann, the Brawley, 
or the Dabney-Pynchon devices may be obtained as follows: 

(a) Introduce the nasal tip or tips into the anterior naris, turn on 
the exhaust power (hand bulb, water, or compressed air, according to the 
apparatus used), and instruct the patient to swallow. This brings the 
soft palate in contact with the posterior wall of the pharynx and closes 
the communication between the epipharynx and the mesopharynx. 
The air in the nose and accessory sinuses and the Eustachian tubes is 
rarefied, and hyperemia of the mucous membrane results. After a 
little practice the patient is able to maintain the state of negative pressure 
for several minutes at a time (Fig. 101). 



Fig. 101 




Showing the soft palate closed during suction through the nose. 



(b) The negative pressure should be alternated every three to five 
minutes with periods of rest, the whole period of treatment extending 
over fifteen to forty-five minutes. 

(c) If the treatment is attended by pain, bleeding, or white edematous 
swelling, the negative pressure is too great and should be reduced. Heat 
in the form of hot air is indicated to counteract the white edematous 
swelling should it occur. 

(d) The nose-piece should be patterned after the Seigel otoscope, so 
that the mucous membrane may be inspected during the course of appli- 
cation of the negative air pressure, and if the membrane becomes pale and 
edematous, or bleeds, the treatment should be abandoned for twenty-four 
hours; that is, paralysis instead of dilatation of the vessels has occurred, 
and the nutrition of the cell structures and the local leukocytosis have 
been still further diminished. The method of treatment, therefore, 
requires the greatest care and intelligent application to be beneficial. 
Its careless and indiscriminate use can only produce harmful effects. 
The greatest objection to the mode of treatment is the ease of applica- 
tion and readiness with which great harm can be done with it. 

Indications. — It should be used: (a) In the first five days of acute 
rhinitis. (6) In the first five days of acute sinuitis. (c) In the first five 



PROMOTING THE REACTION OF INFLAMMATION 129 

days of acute inflammation of the pharyngeal tonsil, (d) In acute tubal 
catarrh, (e) In chronic purulent inflammation of the sinuses. In all 
cases the negative air pressure should be very moderate, as otherwise it 
will produce edema and white swelling and "add fuel to the flames/' 
Its greatest efficiency will be found in acute inflammation. In chronic 
inflammation, either catarrhal or suppurative, heat in the form of hot air 
is a more rational mode of treatment, as it produces an active hyperemia 
and increases the cell nutrition. The negative pressure produces a passive 
hyperemia and leukocytic migration, processes much needed to promote 
speedy resolution of the inflammatory process. 

(e) When purulent secretions are present, they are drawn into the 
bottle reservoir of the apparatus. In these cases the negative air pressure 
not only promotes the inflammatory reaction, but it removes the irritating 
secretions as well. 

(/) The treatment should be repeated every day or every other day. 



CHAPTER VIII 

INFLAMMATORY DISEASES OF THE NOSE 

ACUTE RHINITIS COMPLICATING SPECIFIC FEVERS AND 
CONSTITUTIONAL DYSCRASIAS 

The initial stage of the various exanthematous or specific fevers is 
characterized by an attack of acute rhinitis. Certain constitutional 
dyscrasias also give rise to it. The infectious or exanthematous fevers, 
commonly characterized by an attack of acute rhinitis, are smallpox, 
typhoid fever, acute articular rheumatism, epidemic influenza (la grippe), 
erysipelas, measles, and diphtheria. 

The symptoms of all the foregoing types of specific acute rhinitis are 
about the same, except in diphtheria, in which case a pseudomembrane 
may be present. The usual manifestations found in coryza with con- 
junctivitis and photophobia are present. An examination of the mucous 
membrane of the nose and fauces sometimes shows an eruption quite 
similar to that found on the skin. 

The treatment should consist in the use of mild alkaline solutions with 
an atomizer or a nasal douche. The objection to the douche is the 
possibility of carrying the infection to the middle ear should the patient 
happen to swallow while the fluid is in the nose. The nose should be 
irrigated three or four times daily. 

The constitutional dyscrasias which cause acute rhinitis are diabetes 
mellitus and scorbutus. In diabetic rhinitis the symptoms when 
present rise and fall with the percentage of sugar in the urine. Scorbutic 
rhinitis is associated with infantile scurvy, and is characterized by an 
excoriation about the nasal orifice. 

The treatment should be addressed to the relief of the local nasal 
symptoms and to the improvement of the constitutional dyscrasias. 



ACUTE RHINITIS 

Synonyms. — Acute coryza; cold in the head. 

Definition. — Acute rhinitis is an acute inflammation of the mucous 
membrane of the nose and accessory sinuses, characterized by chilly 
sensations, lassitude, nasal discharge, and a swelling of the mucous 
membrane of the nose. The patient also complains of a stuffiness of the 
nose and of sneezing. 

Etiology. — The chief predisposing cause of acute rhinitis in adults is 
an obstructive lesion of the nasal septum, which predisposes to the local 
(130) 



ACUTE RHINITIS . 131 

growth of the pathogenic bacteria and the development of their toxins, 
hence the inflammatory reaction in the form of an acute rhinitis. The 
ridge or other deviation of the septum impinges upon, or is closely 
approximated to, the inferior nasal concha (inferior turbinated body), 
thus interfering with drainage and ventilation of the nose and accessory 
sinuses. When the anterior portion of the septum is thus deformed it 
obstructs the breath way, and each descent of the diaphragm acts like the 
piston valve of a syringe and rarefies the air in the nasal chamber posterior 
to die obstruction. The negative pressure thus created causes the blood 
to fill the vascular tissue of the "swell bodies" on the inferior and middle 
turbinate, hence the stuffiness of the nostrils. Furthermore, the me- 
chanical irritation caused by the pressure of the ridge or other deviation 
against the turbinate still further aggravates the irritation and swelling 
of the mucous membrane. The secretions are thereby increased in 
quantity and changed in character. 

Inquiry usually elicits the statement that the patient (if an adult) 
has been inclined to chronic rhinitis; indeed, a complete examination 
often shows the patient to have been subject to acute exacerbations of a 
chronic rhinitis, and that a septal deformity is present. Septal deformity 
is not, however, always present, hence each case should be studied 
for its peculiar etiological factors, s.o that the treatment for the ultimate 
cure and prevention of the acute exacerbations may be intelligently 
directed. 

Another very common cause of acute rhinitis is a disturbance in 
the vasomotor nervous system. There is a paralysis of the vasocon- 
strictor muscle fibers of the capillaries, or an irritant in the blood which 
affects the dilator fibers. 

The paresis and irritation may be due to the presence of uric acid and 
its kindred products or to other acquired dyscrasia. The lack of balance 
of the vasomotor nervous system may also be due to the inadequate 
ventilation of the living and sleeping rooms, offices, etc., or to the wearing 
of improper clothing. The removal from the country to the city is often 
followed by frequent attacks of acute rhinitis on account of the changed 
conditions of living. In the country the houses are less tightly con- 
structed and but partially heated, whereas in the city the houses are more 
tightly constructed and either overheated or, as is often the case, are 
underheated in all rooms. In either case the conditions are less healthful 
in the city dwelling because fresh oxygen is a negligible quantity on 
account of the poor ventilation. Then, too, residents of the country spend 
much of the day in the open air, whereas those in the city spend much of 
the time in crowded and illy ventilated offices and shops. It is obvious, 
therefore, that rhinitis due to poor ventilation should be treated by 
changing the mode of living to one which keeps the patient in the open 
air or in a well-ventilated residence and business building. 

The causative relationship of clothing to acute rhinitis is unquestioned, 
though it is difficult to describe the exact mode of clothing that predis- 
poses to rhinitis. It may be said, however, that clothing which promotes 
perspiration is pernicious. There is normally some evaporation of 



132 THE NOSE AND ACCESSORY SINUSES 

moisture from the body, hence the underwear should be of such material 
as to absorb it readily. The function of underwear is twofold, namely: 
(a) To retain the body heat between it and the skin; (b) to absorb the 
excess of perspiration. If, therefore, the clothing is of such density 
that it causes undue perspiration, and of such material that it does not 
absorb it, the conditions are favorable for the development of acute 
rhinitis, even though the septum is normal. Wool retains the body heat, 
but is a poor absorbent. Cotton is neither a good heat retainer nor an 
absorbent. Linen is a fair heat retainer and a good absorbent. In some 
cases wool retains too much heat and induces profuse perspiration. A 
garment of wool and cotton, or wool and linen, or of thin linen under a 
light woollen garment, seems to be suitable to the proper protection of 
the body. Linen mesh in some cases is insufficient protection during 
the winter months for some people, whereas it is worn with the greatest 
comfort and satisfaction by others throughout the year. It should be 
determined in each case whether the rhinitis is due, in part, at least, to 
excessive protection and perspiration, or to deficient absorption of the 
perspiration. Then, too, the question extends to the outer garments 
worn both indoors and outdoors. For the sake of convenience, the outer 
garments should be lessened or added to as the exposure to the tempera- 
ture and weather demands, while the undergarments should be of 
moderate weight and capable of absorbing the visible and invisible 
perspiration. 

A preexisting chronic rhinitis is a common factor in the causation of 
acute rhinitis, especially in adults, whereas infants and young children 
are more susceptible, and often have colds in the head without a pre- 
existing chronic rhinitis. 

As stated in Chapter VI, inflammation is almost always of bacterial 
origin, the condition necessary for the growth of the bacteria being a 
lowered vitality of the cells of the tissues. I also stated that mucous 
membrane-lined cavities with blocked drainage and ventilation were 
especially subject to infection and inflammation. Trauma, chemical 
injury, and shock also lower the cell vitality and prepare the soil for 
infection and inflammation. Exposure to cold and draughts are com- 
mon sources of shock that result in acute coryza or inflammation of the 
nasal mucous membrane; hence, obstructive lesions of the nasal septum 
are not always present in patients subject to acute coryza. Certain 
constitutional diseases, as diabetes, rheumatism, etc., reduce the vitality 
of the mucous membrane of the nose and accessory sinuses, and are, 
therefore, predisposing causes of this disease. All conditions, local 
and general, which lower the resistance of the mucous membrane of 
the nose act as predisposing causes to infection and inflammation of 
the nasal mucous membrane. I wish to emphasize again the fact that 
in many instances the chief predisposing cause of acute coryza (acute 
infectious inflammation of the nasal mucous membrane) is an obstruc- 
tive lesion of the septum. The influence of exposure to cold, draughts, 
foul air, poor ventilation of houses, offices, etc., have heretofore been 
given undue prominence, to the neglect of nasal stenosis (partial and 



ACUTE RHINITIS 133 

complete), which so often bears an important relation to this disease. It 
follows that chronic rhinitis is often present in persons subject to recurrent 
attacks of coryza, a condition which still further lowers the vitality of 
the membrane and predisposes to the growth of bacteria and the devel- 
opment of their toxins, which excite the inflammatory reaction known as 
coryza, acute rhinitis, and "cold in the head." 

In emphasizing these facts I do not w T ish to obscure or belittle the 
other factors that reduce the vitality of the tissues and which predispose 
to the acute inflammatory disease. I only wish to give a true perspective 
to the underlying causes of acute coryza, so that in the treatment a more 
rational basis of procedure may be adopted. 

Acute rhinitis undoubtedly has an infectious origin, and the foregoing 
etiological factors predispose to the infection. Nasal polypi and other 
morbid processes within the nasal chambers also predispose to rhinitis. 

Pathology. — The vasomotor constrictor muscle fibers of the capil- 
laries are paralyzed and the dilator fibers irritated, and, as a consequence, 
there is a passive hyperemia of the venous capillaries and lymph vessels, 
and the nose becomes "stuffed." There is also an increased migration 
of leukocytes and a transudation of lymph and serum. The production 
of mucus is temporarily checked, but later is increased. The epithe- 
lium is exfoliated and admixed with the other inflammatory products 
and secretions. 

During the first stage the secretions are greatly reduced in quantity or 
are entirely absent. In the second stage the secretions are at first serous, 
and later become thick and viscid from the excessive degeneration of 
the goblet and glandular epithelial cells. In the third stage the secretions 
are mucopurulent or purulent in character. 

The duration and course of the inflammatory process varies. The 
course of the average case is completed in from eight to ten days, though 
under appropriate treatment it may be greatly shortened. 

Symptoms. — The symptoms are, for clinical purposes, divided into 
three groups, as follows : 

First Stage, or Onset. — The patient experiences a sense of dryness or 
prickling in the nose, with itching at the inner canthi of the eyes. Chilly 
sensations and a feeling of malaise are complained of. Examination 
shows the mucosa to be red and hyperemic, but not fully turgescent. 
The mucous membrane is abnormally dry and free from secretions. 
Headache is usually present, and there is a sense of fulness between 
the eyes. This stage lasts but a few hours. The temperature ranges 
from 100° to 103°. 

Second Stage. — This stage is characterized by a profuse serous discharge 
and turgescence of the mucous membrane. In some cases the headache 
and the sense of fulness between the eyes are diminished, whereas 
in others they are increased, depending upon the patency or closure 
of the ostei of the accessory sinuses. In those cases in which there is a 
marked deviation of the nasal septum in the region of the middle turbinate 
the obstruction to drainage on one side may be great and the pain and 
sense of fulness correspondingly increased on that side. 



134 THE NOSE AND ACCESSORY SINUSES 

Third Stage. — This stage is characterized by a mucopurulent or puru- 
lent discharge and by a marked decrease in the temperature. The 
headache and the sense of fulness between the eyes may be diminished 
to a dull heavy feeling across the forehead and between the eyes. If 
the nasal accessory sinuses are also markedly involved in the inflam- 
matory process, the frontal headache and the sense of pressure are 
correspondingly pronounced. If the sinuses are not involved these 
symptoms may be entirely absent. Dizziness and vertigo also may be 
present if the sinuses are involved. 

The use of the eyes in reading, sewing, or at the theatre often pro- 
duces headache or other evidence of ocular irritation when the sinuses 
are involved in acute rhinitis. 

Prognosis. — The natural duration of acute rhinitis is from eight to ten 
days. When the sinuses are extensively involved the duration is extended 
to two weeks, or even longer, unless the attack is aborted by appropriate 
treatment. Some writers claim that there is no curative treatment of 
acute rhinitis. I believe this to be an erroneous view, and hold that 
nearly all cases may be cured if taken sufficiently early and rational 
treatment is used. 

Treatment. — The treatment of acute rhinitis should be undertaken 
with a knowledge of the nature of inflammation and the chief predis- 
posing and active etiological factors in mind. These are (a) obstructive 
lesions; (b) lowered tonicity of the cellular structures of the nasal mucous 
membrane, and (c) the infectious microorganisms. 

(a) If there is an obstructive lesion in the nose it should be located 
by rhinoscopic examination. When found, and demonstrated to be 
spongy or erectile tissue, local applications of cocaine, adrenalin, and 
antipyrine should be made to this region to reduce the swelling and to 
establish the patency of the nasal chambers. By so doing drainage and 
ventilation are reestablished, points of immense value in promoting the 
reaction against bacteria and toxins which cause the disease. It is not 
advisable to attempt to remove by surgical means the obstructive lesion 
during the acute symptoms, though such a procedure may well be under- 
taken after they have subsided. The retention of the secretions and the 
lack of ventilation, together with the mechanical irritation from pressure, 
aggravate the existing irritation and tend to perpetuate the reaction of 
inflammation and prolong the disease. The reaction is often inadequate 
to throw off the bacteria and their toxins, hence measures should be used 
that will promote the reaction of inflammation, which is Nature's effort 
to cure the disease. 

The question naturally arises, How may the reaction of inflam- 
mation be promoted? That is, what measures may be adopted that 
will aid in combating the bacteria and their toxins? As stated in the 
section on Inflammation, acute inflammation consists in three reac- 
tions, namely: (a) Increased hyperemia, (b) increased cell nutrition, and 
(c) increased migration of leukocytes. The purpose of these reactions 
is (1) to increase the vitality of the attacked tissues, (2) to remove the 
bacteria and toxins, and (3) to remove the dead and broken-down cells. 



ACUTE RHINITIS 135 

The increased hyperemia furnishes extra food for the cells which have 
been attacked and weakened, while the increased migration of leukocytes 
provides for the destruction and removal of the invading bacteria and the 
dead and broken-down cells. Adami has shown that in acute inflamma- 
tion the inflammatory reaction is usually inadequate for these purposes, 
although it has generally been thought to be excessive. He advises, 
therefore, that acute inflammations be treated by such methods as will 
promote the reaction of inflammation, rather than check it. Formerly, 
remedies which acted favorably upon acute inflammations were said to 
lessen the inflammatory reaction, whereas a more correct and scientific 
statement is, that the remedies promoted the inflammatory reaction 
(Nature's effort to rid the tissues of bacteria and their toxins) and 
thereby hastened the cure of the disease. It is with this understanding 
that I advise the use of such remedial measures as will promote the 
reaction of inflammation. 

The empirical use of drugs has long been practised, and must doubtless 
continue to be practised until their action is better understood. We 
know enough about a few of them to criticise their use in acute coryza. 
Adrenalin has been much used in this disease because it was thought 
that the progress of the disease would be affected favorably by reducing 
the inflammatory reaction. I believe that its use for this purpose is 
contraindicated except as a temporary measure to establish drainage 
and ventilation, because the inflammatory reaction is an effort to remove 
certain noxa or irritants from the tissues, and should not, therefore, 
be checked by the local use of adrenalin or any other substance. The 
physician should recognize the activities known as inflammation as 
forces directed against a noxious foe, and should aid or promote them 
rather than thwart or check them. The chief difficulty in arriving 
at a correct understanding of inflammation is that the results of in- 
flammation are confused with the process itself. When I advise the 
promotion of inflammatory reaction, I do not mean that it should be 
made worse, that cell proliferation should be increased, that the pain and 
soreness should be increased, that adhesive processes should be encour- 
aged, etc. These are the results of inflammation, and are not essential 
features of the reaction. What I mean by promoting the reaction of 
inflammation is to use such treatment as will increase the hyperemia, 
the cell nutrition, and the migration of leukocytes. By so doing the 
irritant noxa is removed, and the cell proliferation, pain, and adhesive 
processes are quickly relieved or altogether prevented. 

W 7 hile the methods of treatment to be given are somewhat hypothetical, 
and in some instances purely empirical, they have been rather extensively 
tried, and have proved to be of more or less value in promoting the 
inflammatory reaction of acute coryza; that is, they have hastened the 
destruction of the bacteria and noxa which cause the disease. 

(b) The tonicity of the vasomotor nervous system should be main- 
tained by the administration of strychnine and arsenous acid in the usual 
tonic doses. Furthermore, the patient should have plenty of fresh air 
in his room if it can be arranged without exposing him to a draught. 



136 THE NOSE AND ACCESSORY SINUSES 

The administration of aconite or belladonna may be resorted to for the 
immediate effect upon the turgescence and the secretions, especially in 
the second stage. An alcohol rub over the entire body also acts as a 
tonic to the vasomotor nervous system and increases the hyperemia of 
the arterioles and capillaries, and thereby increases the nutrition of the 
mucous membrane. 

(c) While it has not been shown that the disease is due to a specific 
microorganism, it is evident that bacteria are the exciting cause. An 
endeavor should be made, therefore, to establish conditions favorable 
for their destruction and elimination. This should be done by establish- 
ing and maintaining drainage and ventilation and promoting the reaction 
of inflammation. The use of antiseptics has no effect in destroying the 
bacteria, though they do promote reaction of inflammation. Surgical 
experience has shown that free drainage is of prime importance in the 
treatment of infected cavities, as, for instance, in septic peritonitis com- 
plicating a ruptured appendix. Irrigation of the abdominal cavity has 
been abandoned and simple drainage substituted, with brilliant results 
The same principle applied to acute infectious inflammations of the 
nasal and accessory sinuses brings equally good results. Hence, the 
mode of treatment described in paragraph (a) will, in most instances, 
meet the indications. If it does not, the obstructive lesions of the septum 
(or other lesion) should be removed by surgical means at the earliest 
possible time, so as to prevent such a complication during subsequent 
attacks of acute rhinitis. 

In addition to the foregoing measures, the use of the leukodescent 
lamp over the nose and eyes is recommended, to promote the reaction of 
inflammation. The light from this lamp is rich in blue violet rays, in 
addition to the heat rays, and they exert a powerful and immediate 
salutary effect upon the inflammatory process; that is, they greatly 
increase the hyperemia and the leukocytosis, and thus dispose of the 
bacteria, their toxin, and the dead cells of the tissues. Having done 
this, the reaction often rapidly subsides and a cure results. 

A treatment with the lamp should cover a period of from twenty to 
thirty minutes. It should be placed at a distance of about eighteen to 
twenty inches from the face. The light is more effective if applied over 
the closed eyes, as the tissues are soft and easily penetrated by the rays, 
and because the veins of the accessory sinuses empty into the ophthalmic 
vein. Hence, any increased flow through the ophthalmic vein promotes 
the flow from the veins of the sinuses and the nose. As acute rhinitis 
is essentially an acute sinuitis, the reaction affecting the sinuses effects 
speedy relief or a cure. 

The above mode of treatment is based upon rational principles, 
which, for the sake of emphasis, are recapitulated here: 

(a) Establishment of ventilation and free drainage of the nasal 
accessory sinuses. 

(b) Establishment of tonicity of the vasomotor nervous system. 

(c) Promotion of elimination of the bacteria by drainage and venti- 
lation of the nasal and accessory sinuses. 



CHROXIC RHIXITIS WITH TURGESCENCE 137 

(d) Promotion of reaction of inflammation by the leukodescent 
light. 

Other Methods of Treatment. — 1. The administration of full doses of 
quinine and a hot lemonade at bedtime will, in some instances, during 
the first stage, abort acute rhinitis by increasing the hyperemia and 
leukocytosis. If given during the second or third stages they are 
ineffective. This method is not as efficacious as the one given above, 
but is worth trying. 

2. Ten grains of Dover's powder and a hot mustard foot bath at bed- 
time promote the reaction of inflammation to a considerable degree, and 
if given during the first stage may abort the disease. During the second 
and third stages it is more difficult to promote the reaction of inflamma- 
tion, hence this mode is not sufficiently effective in these stages to be of 
much value. 

3. The administration of rhinitis or coryza tablets, containing quinine, 
belladonna, and morphine, during the first stage will often abort acute 
rhinitis. One tablet should be given every twenty minutes until dryness 
of the nose is produced. 

4. Aconite administered hourly in the first stage in 1 minim doses 
until dryness of the throat or tingling of the fingers is produced will 
sometimes abort the disease. During the second and third stages the 
remedy is of little use. 

Cathartics should always be given early in the disease. 



CHRONIC RHINITIS WITH TURGESCENCE 

Synonyms. — Alternating stenosis; simple chronic rhinitis. 

Definition. — Chronic rhinitis with turgescence is characterized by 
fugitive swelling or turgescence of the "swell bodies" of the inferior 
turbinates, and the patient complains of attacks of nasal obstruction 
and a thick mucous discharge. 

Etiology. — The causes of chronic rhinitis are given under the etiology 
of acute rhinitis, and will not be repeated in detail. It should be stated, 
however, that in most cases there is a deviation of the septum in its lower 
and middle portion. The deviation may also be an anterior one near the 
vestibule of the nose in the cartilaginous portion of the septum, thereby 
producing anterior nasal stenosis. With each descent of the diaphragm 
the air is rarefied posterior to the obstruction, and a negative pressure in 
the nasal chambers results. The blood in the mucous membrane lining 
the nasal chambers is thus drawn to the venous plexuses (swell bodies) 
of the turbinates, and turgescence or engorgement results. 

In the section on Deviations of the Septum it has been shown that 
obstructive lesions in the region of the inferior turbinal act in such a 
way as to produce engorgement of the tissues without much irritation. 
Hence the effect at first is simply one of turgescence, which in the 
course of years of increased nutrition results in hypertrophy or hyper- 
trophic rhinitis. If in addition to the local turgescence there is an asso- 



138 THE NOSE AND ACCESSORY SINUSES 

ciated obstruction in the region of the middle turbinal, the retention and 
decomposition of the secretions in the superior meatus and the posterior 
ethmoidal cells cause a prolonged low-grade irritation which may result 
in a hyperplasia of the mucous membrane, not only of the middle turbinal, 
but of the ethmoidal cells as well. As an obstructive lesion of the septum 
in the middle turbinal region often co-exists with the obstructive ridge or 
spur in the inferior turbinal region, hyperplasia or hyperplastic rhinitis 
affecting the inferior and middle turbinate is often present. When, 
however, the upper obstruction is absent, the rhinitis is usually of the 
turgescent or hypertrophic type. 

Pathology. — In the early stage there is a distention of the venous or 
cavernous tissue of the conchse (turbinates). If the inflammatory process 
continues a true hypertrophy of the tissues takes place on account of the 
increased nutrition from the large blood supply. 

Symptoms. — The symptoms are chiefly caused by transient stenosis 
of the breath way of the nose. In addition, the secretions are heavier; 
that is, the mucoid element is increased, while the serous element may 
be decreased in quantity. The patient believes there is an actual increase, 
whereas, as a matter of fact, there is probably a decrease in the amount 
of secretion. The apparent increase is due to the greater consistency of 
the secretion, which renders it less absorbable by the ingoing current 
of air. In a normal nose the secretions are comparatively thin or serous, 
and are largely absorbed for physiological purposes and carried to the 
lower respiratory tract. 

The transient stenosis is either intermittent or alternating; that is, 
both sides may be stenosed for a period and then open, or the stenosis 
shifts from one side to the other. These symptoms are quite character- 
istic of turgescent rhinitis. 

The objective signs of turgescent rhinitis are chiefly found in the 
evidences of engorgement of the "swell bodies" of the inferior turbinates. 
Upon inspection by anterior rhinoscopy, the outline of the inferior 
turbinate is smooth and boggy-like, whereas, in true hypertrophic rhinitis 
it is firm and unyielding. The application of cocaine or adrenalin causes 
shrinkage of the mucous membrane which covers the inferior turbinate, 
whereas in hypertrophic rhinitis there is little or no shrinkage. 

The secretions are mucoid in character, and when the "swell bodies" 
are contracted, strings of mucus extend from the septum to the inferior 
turbinate. 

A spur or ridge is usually present upon the lower portion of the septum, 
causing obstruction in some degree in the region of the inferior turbinate. 
The cartilaginous portion of the septum may also be deflected, thereby 
causing anterior nasal stenosis and a consequent rarefaction of the air 
within the nasal chambers with each inspiratory current. 

Epistaxis is also occasionally complained of. The ridge or crest of the 
septum projects into the inspiratory tract, and is thereby subjected to 
excessive evaporation of the secretions accumulated upon it. The dried 
crusts are blown or picked off, tearing the underlying epithelium and the 
capillary vessels; hence the epistaxis. 



CHROXIC RHINITIS WITH TURGESCENCE 



139 



Cough when present is due to an associated bronchitis or laryngitis. 

Posterior rhinoscopy reveals an enlargement of the "swell bodies" 
upon the posterior ends of the middle and inferior turbinates. The 
enlargement has. often been likened to a mulberry. It is nodular in 
outline and of a grayish-blue color. 

Prognosis. — If allowed to run its course, true hypertrophy and a 
lessened functional activity of the tissue occurs. Under appropriate 
treatment the disease is curable. 

Treatment. — The treatment should be twofold in character : (a) The 
removal of the predisposing causes, and (b) the control of the immediate 
symptoms. 

(«) The removal of the predisposing causes is usually accomplished 
by the correction of the deviated septum. (See Treatment of Deviations 
of the Septum.) When this is done the negative air pressure in the nasal 



Fig. 102 




Method of moistening a thin pledget of cotton with cocaine or adrenalin solution: a, the solution 
in an inverted bottle; b, the pledget of cotton. 



chambers disappears and the blood ceases to be drawn to the mucous 
membrane, and the tendency to intermittent and alternating stenosis 
is greatly reduced. The choice of operation should be determined 
according to the type and location of the deviation of the septum. 

(b) The palliative treatment should be addressed to the immediate 
control of the distressing symptoms, namely, the stenosis and the heavy 
secretions. The transient stenosis may be controlled by the use of the 
electric or chemical cautery or by incising the turgescent "swell bodies." 

Electrocauterization. — The technique of electrocauterization is as 
follows : 

(a) Induce cocaine anesthesia by the application of a 4 per cent, solu- 
tion of cocaine on a thin pledget of cotton to the swollen free border 
of the inferior turbinate for a period of ten minutes (Figs. 102 and 103), 



140 



THE NOSE AND ACCESSORY SINUSES . 



(b) Turn on the electric current until the point of the cautery electrode 
is of a bright cherry-red color. 



Fig. 103 




Method of applying the pledget of cotton to the inferior turbinated body: a, the pledget of 
cotton after being moistened with the cocaine or adrenalin solution is engaged upon the tip of a 
delicate silver probe; b, the pledget of cotton being ' 'pasted" or spread upon the inferior turbinated 
body. 

(c) Introduce the electrode into the nasal chamber cold and place it 
on the free border of the inferior turbinate (Fig. 104). Then move it 
backward and forward, while still cold, until sure of its correct position. 
Maintain the to-and-fro motion and press the contact spring of the 



Fig. 104 




Lateral view, showing the cautery electrode in position for cauterizing the inferior turbinated body. 



cautery handle for one or two seconds, when the contact should be 
broken. The to-and-fro motion should be continued until the electrode 
is cold, that is for two or three seconds after the spring contact is broken, 
and then it should be removed from the nose. 



CHRONIC RHIXITIS WITH TURGESCENCE 



141 



If these instructions are followed, the procedure is painless and does 
not tear the eschar from the turbinal. If the to-and-fro motion is not 
maintained before, during, and after the electrode is heated, the eschar 
will be torn off and the cautery effect lost. 

The eschar must be left in place. If bleeding follows the removal of 
the electrode, the eschar is lost and the cauterization rendered useless. 

The cauterization should be linear, and should be about one inch in 
length. The whole length of the inferior turbinate may be cauterized 
in three sittings (Fig. 105), never in one, as too great a reaction and 
sloughing may follow. 

The sittings should be from five to seven days apart. A week after 
the first cauterization the opposite side may be treated in like manner. 
At the end of another week the middle portion of the inferior turbinate 
first cauterized may be thus treated. And so continue to cauterize the 
turbinates alternately, at weekly intervals, until the whole length of both 
turbinates has been cauterized. 

The after-treatment of a cauter- Fig. 105 

ized turbinate should consist in an 
immediate spray of an alkaline 
solution — Dobel's or Seller's solu- 
tion. An oily aromatic nebula 
should follow this. Prescribe 
Seller's solution for daily use by 
the patient. The wash should 
be used with a glass nasal douche 
rather than an atomizer, as the 
force of the spray might injure 
the cauterized surface. 

Should infection occur, gently 
pack the nose with small cotton 
pledgets saturated with a 10 per 
cent, aqueous solution of Merck's 
ichthyol. Remove the pledget in 
about fifteen minutes and insuf- 
flate bismuth powder into the 

nose. The clothing of the patient should be regulated according to 
indications. Heavy-soled shoes should be prescribed. 

Submucous Cauterization. — N. H. Pierce first introduced the submucous 
cauterization of the inferior turbinated body for the reduction of turges- 
cent and hypertrophic rhinitis. The mucous membrane is punctured 
near the anterior end of the free border of the turbinate and a tunnel 
made with a blunt probe beneath the turgescent membrane. A fused 
bead of chromic acid is then introduced into the artificial tunnel or 
channel. M. A. Goldstein improved the instruments for this procedure, 
as shown in Fig. 106. By Goldstein's method the bead of chromic acid 
is concealed in the cannula while being introduced, the fused bead of 
acid then being thrust from the end of the cannula and withdrawn 
through the channel in the submucous tissue. 




:>U-f* \^\ 



Showing the lines for linear cauterization in 
turgescent rhinitis: A, B, and C, representing 
respectively the first, second, and third cauteriza- 
tions, which should be made one week apart. 



X42 THE NOSE AND ACCESSORY SINUSES 

Sloughing sometimes follows this method of cauterization. Chromic 
acid is very irritating to the kidneys and may cause nephritis. It should 
never be used in a patient already subject to nephritis, for obvious 
reasons. 

Fig. 106 

^ =_^= 4 




Goldstein's chromic acid applicator for submucous cauterization. 



HYPERTROPHIC RHINITIS. 

Synonyms. — True hypertrophic rhinitis; obstructive rhinitis; hyper- 
trophic nasal catarrh ; hypertrophic ozena ; hypertrophy of the turbinated 
bodies; hyperplastic rhinitis. 

Definition. — -Chronic hypertrophic rhinitis is characterized by a 
partial stenosis of the nasal chambers, due to hypertrophy of the 
mucous membrane of the inferior turbinated body. 

Etiology. — The causes of hypertrophic rhinitis are essentially those 
given under turgescent rhinitis. When there is an anterior devia- 
tion of the septum there is a negative air pressure within the nasal 
chambers with each inspiratory effort. The hyperemia resulting there- 
from leads to an overnutrition of the mucous membrane, especially 
of the "swell bodies." The contact of the deviated septum with the 
mucosa of the inferior turbinal irritates it and thus still further excites 
the hypertrophic process. The altered secretions add to the irritation, 
and still further increase the hypertrophy of the mucous membrane. 

In cases which are complicated by a high deviation of the septum, and 
in which there is a complicating sinuitis (catarrhal or suppurative), the 
tissue changes are somewhat modified. Instead of hypertrophy, 
the irritating discharge from the sinuses often causes hyperplasia of 
the mucous membrane. There may be present, therefore, both 
hypertrophy and hyperplasia of the tissue. Either the hypertrophy or 
the hyperplasia may predominate. The so-called hypertrophic rhinitis 
may, therefore, be divided into two groups : (a) The hypertrophic variety, 
and (b) the combined hypertrophic and hyperplastic variety. This 
subdivision is still further justified by the clinical fact that the symp- 



HYPERTROPHIC RHINITIS 143 

tomatology and treatment of the two conditions are often quite different. 
The hypertrophic variety presents symptoms which are due chiefly 
to the anterior and the inferior obstruction of the nose, whereas the 
combined variety presents symptoms due to obstruction in the middle 
turbinal region as well as to the obstruction in the anterior and inferior 
portions of the nasal chambers. 

The causes of uncomplicated hypertrophic rhinitis are, therefore, 
those conditions which give rise to a chronic hyperemia of the mucosa 
and to a passive engorgement of the "swell bodies." These conditions 
are the anterior and inferior obstructive deviations of the nasal septum 
and the climatic and hygienic conditions which affect the vasomotor 
nervous system. 

Pathology. — The morbid anatomy of hypertrophic rhinitis consists 
in an increased blood supply and an increase of tissue from nutritional 
rather than from irritative and inflammatory causes. The part most 
frequently hypertrophied is the mucous membrane containing the 
''swell bodies," as there is naturally a greater flow of blood through 
these vascular bodies. 

Symptoms. — The symptoms are chiefly those of more or less nasal 
stenosis. The secretion is usually heavier than normal, and pasty in 
consistency, although it may be comparatively thin and watery, especially 
during an acute exacerbation. 

The nasal stenosis may be limited to one side, the side of greater septal 
convexity. The inferior turbinate on the side of the concavity is often 
greatly hypertrophied, a so-called compensatory hypertrophy, although, 
as a matter of fact, it may be due to a negative air pressure within the 
nasal chamber on that side. The anterior opening of the nose on that 
side, while normal in size, is, on account of the diminished size of the 
opposite chamber, inadequate to admit air rapidly enough for phy- 
siological purposes; hence, engorgement and subsequent hypertrophy 
results. It follows that both nasal passages are often more or less con- 
stantly blocked in the region of the inferior turbinate. The patient com- 
plains of stuffiness, or sense of a foreign body in the nose, and makes 
frequent but ineffectual attempts to remove it by blowing the nose. 

Upon anterior rhinoscopic examination the inferior turbinal is observed 
to be enlarged and to have an irregular nodular surface. Probe pressure 
does not cause pitting, as in turgescent rhinitis, but elicits a sense of 
resistance and of thick fleshy tissue. The application of cocaine or 
adrenalin is not followed by marked contraction of the tissue. 

Epistaxis from the dislodgement of an adherent crust upon the crest 
of the deflection occasionally occurs. 

Prognosis. — If allowed to run its natural course, hypertrophic rhinitis 
tends to become worse rather than better. Indeed, in the course of 
time the secretions may become so heavy and so adhesive in quality 
as to be removed with great difficulty. In such subjects irritation results 
and hyperplasia of the tissue follows. If this is allowed to progress 
the vascular and glandular tissues become enmeshed in the contractile 
hyperplastic tissue, and atrophy of the mucous membrane begins. 



144 THE NOSE AND ACCESSORY SINUSES 

If, on the contrary, appropriate treatment is instituted sufficiently 
early, the prognosis is fairly good. 

Treatment. — The treatment consists mainly in overcoming the 
stenosis and removing a part or all of the hypertrophic tissue. Sprays 
and douches of alkaline antiseptic solutions do little more than tem- 
porarily increase the reaction of inflammation and relieve the symptoms 
by the removal of the altered secretions. The nasal stenosis is overcome 
by the surgical correction of the septal deformity and the removal of the 
excessively hypertrophied turbinal tissue (Fig. 107). (See Obstructive 
Deviations of the Septum and the Methods of Correcting Deviations 
of the Septum.) Be assured that in most instances hypertrophic 
rhinitis is a surgical rather than a medical disease. Be assured, also, 
that hypertrophic rhinitis cannot be cured by sprays and other local 
medicinal applications, although they may temporarily relieve some of 
the symptoms. 

The actual cautery has been recommended for the reduction of 
hypertrophied mucous membrane. I can only condemn it as inade- 
quate for this purpose. If it is used freely enough to accomplish any- 
thing, it produces excessive scar 
f ig . 107 tissue, a result to be carefully 

avoided. 

Surgical Treatment. — If the hy- 
pertrophy is great enough to ob- 
struct the nasal passages, it should 
be removed surgically with scissors, 
saw, or spokeshave. 

Hypertrophy of the mucous membrane of The SdsSOrS. The ScisSOrS are 

the inferior turbinated body: a, anterior at- generally used for the removal of the 

tachment; p, posterior attachment. Removed P " 1 • a <• p .1 i» 

by the author with his turbinotome. (Dr. hypertrophied portion of the tree 
Henrietta Gould's case.) border of the inferior turbinated 

body. The technique is as follows : 

(a) Induce local anesthesia by the application of a 5 per cent, solution 
of cocaine by means of a thin pledget of cotton, which should be placed 
over the hypertrophied area for ten minutes. 

(6) With nasal scissors (Fig. 108) cut off the necessary portion of the 
hypertrophied membrane. 

(c) Use no dressing except an antiseptic dusting powder. An exception 
may be made, however, in favor of PischePs collodion dressing if perfect 
dryness of the parts can be secured. 

(d) If severe hemorrhage occurs, it becomes necessary to pack the 
nose in order to check it. This may be done by introducing a postnasal 
tampon with Bellocq's cannula (Fig. 109), or with a rubber urethral 
catheter. A long strip of gauze should then be packed against it through 
the anterior nares. When such a tampon is used it should be moistened 
with the compound tincture of benzoin or impregnated with bismuth 
powder to prevent decomposition of the secretions. When either of 
these precautions is taken the tampon may be left in place for three or 
four days without putrefaction. 




HYPERTROPHIC RHINITIS 



145 



The Saw. — The saw may be used instead of the scissors when it 
is necessary to remove a portion of the inferior turbinated bone with 
the hypertrophied membrane (Holmes, Vail). 

Technique. — {a) Induce local anesthesia with cocaine. 

(b) Introduce a slender nasal saw beneath the inferior turbinated 
body and saw in an inward and upward direction through it. If it is 

Fig. 108 




Beckmann's serrated scissors. 



Fig. 109 




Fig. 110 



Bellocq's postnasal tampon cannula. 

impossible to insert the saw beneath the turbinated body it may be 
introduced above it and the incision carried downward and outward 
through the tissue. 

(c) Either use no dressing or use the Pischel collodion dressing when 
conditions are favorable, that is, when all hemorrhage ceases. 

The Spokeshave. — The spoke- 
shave may be used if it can be en- 
gaged posteriorly in such a position 
as to enable the operator to control 
its direction in cutting forward. 
This operation is rarely justifiable, 
as too much of the turbinate is 
removed by it. 

The Technique. — (a) Induce local 
cocaine anesthesia. 

(b) Make a linear incision along 
the mediosuperior surface of the 
inferior turbinate just at the upper 
margin of the hypertrophied tissue 
(Fig. 110). The incision is for the 
purpose of preventing laceration of 
10 




Showing the incision preliminary to the re- 
moval of the inferior turbinated body with the 
spokeshave or swivel knife. 



146 



THE NOSE AND ACCESSORY SINUSES 



the mucous membrane as the spokeshave is drawn through it. Healing 
is promoted by making a clean cut. 



Fig. Ill 




Spokeshave. 
Fig. 112 




'|!|!IIH|;Mn" , :!'Hl:!MI|l"!l l 

,„: .:: IIIW Hill [IIKIIII HIIIHIIIIII ll!ll|l!llllil|i|lPH| 



...: • ___ 



The author's swivel turbinotome. 
Fig. 113 




The removal of the anterior two-thirds of the inferior turbinate with the author's wide 
swivel knife (Fig. 112). 

Fig. 114 




Showing the removal of the inferior turbinate with the author's large swivel knifg. 



HYPERPLASTIC RHINITIS 147 

(c) Introduce the spokeshave (Fig. Ill) at the posterior extremity 
of the turbinate if there is a mulberry hypertrophy there, or along the 
free border of it if only that portion is involved. Engage the turbinated 
body and pull forward in such a direction as to include only the hyper- 
trophic tissue. The spokeshave should not be used unless it is desired 
to remove some bone as well as soft tissue. 

(d) Follow the same method of after-treatment given in the previous 
operations. 

The Swivel Knife. — The author's large swivel knife (Fig. 112) may 
be used with even greater advantage than the spokeshave, as it can be 
made to engage or leave the tissue at any desired point along the free 
border of the turbinate. The knife used for this purpose is especially 
designed with a view to its width and strength. Otherwise it is similar 
to the one used in the submucous resection of the nasal septum. 

The Technique. — (a) Induce local cocaine anesthesia. 

(b) Insert the swivel knife as though it were a spokeshave and force 
the blade into the turbinate posterior to the hypertrophied tissue (Figs. 
113 and 114). When it is sufficiently engaged in the tissue pull it forward, 
as in the spokeshave operation, and disengage it by directing it downward 
toward the floor of the nose when the anterior limit of the hypertrophy 
has been reached. The preliminary incision of the membrane is un- 
necessary, as the cutting edge of the blade is concave and prevents 
laceration of the mucosa. Bone, as well as soft tissue, may be removed 
with it. 

(c) The after-treatment should be the same as in the other operations. 

HYPERPLASTIC RHINITIS 

Synonyms. — The same as given under hypertrophic rhinitis, as the 
two conditions are often confounded. 

Definition. — Hyperplastic rhinitis is characterized by an increase in 
the thickness of the mucous membrane as a result of prolonged mild 
irritation by the secretions from the sinuses. It differs from hypertrophic 
rhinitis in its causation and in its morbid anatomy. In hypertrophy 
there is an increase in the size of the cells from overnutrition, whereas 
in hyperplasia there is an increase in the number of cells, and especially 
of the connective-tissue cells, from the slight but prolonged irritation. 
Polypi are a later development of this condition (see Chapter XIII). 

Etiology. — The chief causes are pressure, or the close approxima- 
tion of the septum to the middle turbinate, the resultant retention of 
the secretions, and the inflammation of the obstructed sinuses. The 
septum does not, in all cases, impinge upon the middle turbinate, and is 
not, therefore, a constant etiological factor in producing the hyperplasia. 
The sinuses may be diseased independently of the septal deviation, and 
may thus be the primary cause of the hyperplasia. In either event 
the irritation resulting from the secretions constantly flowing over the 
mucous membrane of the middle and inferior turbinates causes the 
morbid changes in these structures. The secretion is not necessarily 



148 THE NOSE AND ACCESSORY SINUSES 

purulent, but, on the contrary, is often serous or mucous in character; 
that is, the inflammation in the sinuses may not be suppurative, but 
may be catarrhal in character. 

Symptoms. — The symptoms of hyperplastic rhinitis are often complex, 
as the disease is often associated with a catarrhal or a suppurative inflam- 
mation of the ethmoidal, sphenoidal, and possibly the frontal sinuses. 

The symptoms arising from the hyperplasia are those of nasal obstruc- 
tion, especially in the region of the middle turbinate; that is, there is 
more or less nasal obstruction and a sense of stuffiness or of pressure 
in this portion of the nose. The handkerchief is frequently used in 
efforts to dislodge the secretions and to overcome the sense of stuffiness. 
While the secretions may be thus removed, the stuffy feeling often 
remains, as it is due to the contact of the turbinate with the septum. 

The secretions may be serous, mucopurulent, or purulent, depending 
largely upon the complicating disease of the sinuses. According to 
Uffenorde and Skilleren suppuration is rarely present, indeed, they claim 
that the microscopic appearances of the tissues in suppurative eth- 
moiditis and hyperplastic ethmoiditis or rhinitis are different. Accord- 
ing to my clinical observations hyperplastic ethmoiditis or rhinitis is 
nearly always attended by suppuration, though in less degree than in 
simple empyema without marked hyperplastic changes. 

Anterior rhinoscopy shows the inferior turbinate to be enlarged, paler 
than normal, or it may be red and boggy, and somewhat nodular in 
outline, and polypi may be seen growing from its lower border. The 
enlargement present is due to the hyperplastic change in the mucous 
membrane. If this tissue becomes edematous and pendulous, it consti- 
tutes true polyp. I have often examined specimens of the ethmoid 
bone removed from patients in which the cells were more or less filled 
with small polypi, while other larger polypi protruded from the cells 
through the ostia and were hanging free in the nasal chamber. In view 
of these findings, it is obvious that the removal cf the visible polypi 
would fail to relieve the patient, as the small, budding polypi within 
the cells would sooner or later extend through the ostia into the nasal 
chambers. If the septum is deviated, and it usually is, a ridge corre- 
sponding to the crista nasalis and the crest of the vomer may be 
present on one side, while there is a bowing of the septum toward the 
opposite side in the region of the middle turbinate. The mucous mem- 
brane covering the septum is also often thickened just below the inferior 
border of both the middle turbinate bodies, thereby obstructing both 
olfactory fissures. 

If empyema of the posterior ethmoidal cells (cellulse ethmoidales) is 
present, pus may be seen in the olfactory fissure as well as in the lower 
portion of the nose. If there is catarrhal ethmoiditis, the anterior end 
of the middle turbinate may be red and boggy in texture. Patients 
with this type of ethmoidal inflammation sometimes complain of sore- 
ness or of fissures at the margins of the vestibules. 

The subjective symptoms are due to obstructive lesions and to the 
disease in the accessorv sinuses of the nose. 



HYPERPLASTIC RHINITIS 



149 



The obstruction in the upper part of the nose gives rise to a sense of 
stuffiness and of pressure across the bridge of the nose. These symptoms 
are rather constant, as the tissue enlargement is permanent. 

The obstructive lesion in the upper portion of the nose gives rise to 
the additional symptoms of headache and vertigo peculiar to inflamma- 
tion of the sinuses; that is, there is headache in the frontal region limited 



Fig. 115 




The removal of the anterior end of the middle turbinated body with Casselberry's scissors. 

to, or more pronounced on, one side, and to a feeling of soreness or 
tenderness of the eyeball upon ocular movements. The stooping posture 
increases the headache, and temporary vertigo is often thereby produced. 
The headache is also sometimes in the temporal, vertexial, and occipital 
regions, especially if the posterior ethmoidal and sphenoidal sinuses are 
involved. 

Fig. 116 




Krause's nasal snare. 



The symptoms given in the above paragraph are due to the sinuitis, 
and are not always present in hyperplastic rhinitis. 

Prognosis. — The prognosis of hyperplastic rhinitis is not as favorable 
as that of hypertrophic rhinitis. The etiology is more complex and 
the disease more serious, and it necessitates more extensive surgical 
procedures for its eradication. 



150 THE NOSE AND ACCESSORY SINUSES 

Treatment. — The treatment of hyperplastic rhinitis should have 
two chief objects, namely: (a) The removal of the obstructive lesion, 
whether it be deviation of the septum or hypertrophy of the middle 
nasal concha (middle turbinate), and (b) the cure of the sinuitis, if 
present, whether it be in the ethmoidal and sphenoidal or the frontal 
and maxillary sinuses. 

The Author's Turbinotome. — With the author's turbinal knife (Fig. 120) 
all or any portion of the middle turbinate may be removed under cocaine 
anesthesia. The technique for the removal of the anterior portion is 
as follows: 

(a) Introduce the knife through the olfactory fissure as far posteriorly 
as it is desired to begin the incision. 

(b) Turn the cutting edge of the blade outward and forward and 
force it into the turbinate as far as it will go. 

(c) Then cut forward to the anterior attachment of the turbinated 
body as shown in Fig. 120. 

(d) Remove the severed portion with dressing forceps. 

Fig. 117 




Holmes' middle turbinal scissors. 

The Scissors and Snare. — The technique is as follows: 

(a) Induce local anesthesia with a 10 per cent, solution of cocaine. 
A weaker solution is often inadequate in hyperplastic tissue. 

(6) Grasp the anterior attachment of the middle nasal concha (middle 
turbinate) with the scissors and make an incision about one inch in length, 
thus severing the attachment of the anterior one-third or one-half of the 
middle turbinated body (Fig. 115). 

(c) Introduce a cold wire loop over the detached portion of the turbinate 
and cut it off at the posterior limit of the incision, or sever the detached 
portion of the turbinate with Griinwald's forceps. Still more tissue may 
be removed if necessary. 

Holmes' Scissors. — With Holmes' scissors (Fig. 117) the snare is not 
necessary, as the blades are so curved that the cut made with them 
extends backward and downward until it emerges from the tissue (Figs. 
118 and 119). 



HYPERPLASTIC RHINITIS 



151 



The Swivel Knife. — The technique of the removal of the middle tur- 
binate with the swivel knife differs from that employed with a larger 
instrument in the removal of the inferior turbinate. 

The technique is as follows: (a) Induce local anesthesia with a 10 
per cent, solution of cocaine applied on a thin pledget of cotton over 
the whole of the middle turbinate. It may be necessary to apply a 20 to 
30 per cent, solution, or even powdered cocaine with a delicate cotton- 
wound applicator to the less accessible areas. 

Fig. 118 




The removal of the anterior half of the middle turbinated body with Holmes' scissors. 

Fig. 119 




Anterior half of the middle turbinate removed with Holmes scissors, exposing the bulla ethmoidalis. 

(b) Introduce the small swivel knife and engage the anterior attach- 
ment of the middle turbinate (Figs. 121 and 122), so that one prong tip 
is above and the other below the attachment. 

(e) Carry the swivel blade backward with short strokes until the whole 
or a part of the middle turbinate is severed from its attachment. The 
severed middle turbinate does not pass between the prongs of the instru- 
ment, but is pushed downward beneath them. If only a portion of the 



152 



THE NOSE AND ACCESSORY SINUSES 



middle turbinate is to be removed, the swivel blade is directed downward 
through the turbinate at the desired point, or, failing in this, the swivel 
knife is removed and the loop of a snare is engaged over the detached 
fragment and the removal completed. 



Fig. 120 




The removal of the anterior portion of the middle turbinated body with the author's turbinal 

knife. 



Fig. 121 




The author's narrow swivel knife placed at the anterior attachment of the middle turbinate 
preparatory to removing it. 

Remarks. — The swivel knife is not universally suited for turbinectomy 
or turbinotomy, although in many cases it is an ideal instrument for 
these purposes. In each case the instruments and mode of operation 
should be selected with reference to the conditions present rather than 
to follow blindly any described method of operating. 

(d) The postoperative treatment should consist of the insufflation 
of bismuth powder, and, in case of severe persistent hemorrhage, the 



CHROXIC RHINITIS WITH COLLAPSE OF ERECTILE TISSUE 153 

nose should be packed with bismuth, or compound tincture of benzoin 
gauze. 

Hemorrhage. — The middle turbinate is supplied with blood by the 
anterior and posterior ethmoidal arteries (A. ethmoidalis anterior et 
posterior) (Plate I, Fig. 1), and hemorrhage of considerable severity may 
occur either at the time of operation or at a later period. As a matter 
of fact, an oozing of blood continues in many cases for twenty-four hours. 

The danger of septicemia and of meningitis is increased by nasal 
tampons, hence it is not advisable to pack the nose except in extreme 
necessity. Several cases of meningitis have occurred as a result of 
nasal tampons introduced after middle turbinotomy. The packing 
should be done with caution, and the gauze should be moistened with 

Fig. 122 




The removal of the middle turbinate with the author's narrow swivel knife. 

the compound tincture of benzoin and squeezed until the excess of fluid 
is removed. If the operation is performed in a hospital, it is rarely 
necessary to pack the nose, as the patient remains quiet and severe 
hemorrhage rarely occurs. If it does occur, the house surgeon should 
be instructed to introduce the tampon. 

The chief causes of complications and sequelae after nasal operations 
are, namely: (a) The failure to sterilize the nasal chambers; (b) the use 
of nasal tampons; (c) ragged contused wounds; (d) blowing the nose, 
thus forcing infectious material into the sinuses and cranial cavity. 



CHRONIC RHINITIS WITH COLLAPSE OF THE ERECTILE TISSUE 

Definition. — This is not a true inflammatory disease, but is usually 
classed as such. It is a local manifestation of a general anemia; it 
is characterized by the collapse of the erectile tissue of the nose, and 
resembles atrophy in this region. 

Etiology. — Its chief cause is general anemia. Atrophic rhinitis is 
also characterized by anemia that is secondary to the conditions causing 
the atrophy. In simple collapse of the "swell bodies" the anemia is 



154 THE NOSE AND ACCESSORY SINUSES 

primary and the collapse secondary. It is most often found in women, 
as they are more subject to anemia. It is occasionally found in gouty 
individuals. 

Symptoms. — The chief symptoms are dryness of the upper respiratory 
tract and patency of the nose. Upon anterior rhinoscopic examina- 
tion the inferior turbinates appear quite small, on account of the collapse 
of the "swell bodies." Upon probe pressure the mucous membrane is 
found to be thin and tightly drawn over the underlying bone. The great 
space in the nasal chambers and the small size of the inferior turbinates 
at once suggest an atrophic condition, though true atrophy is absent; 
crusts and ozena are absent, nor is there a history of their previous 
presence. An examination of the blood shows anemia to be present. 
The sense of smell is unimpaired and ulceration of the mucosa and 
caries of the bone are absent. The condition is always bilateral, as it 
is due to constitutional rather than local causes. 

Treatment. — The treatment should be directed to the anemia. It 
is necessary, therefore, to ascertain the type of the anemia by blood 
examinations and to carry out the treatment accordingly. I wish to 
suggest that an examination of the rectum will sometimes reveal ulcera- 
tions or other pathological processes that may be the cause of the 
anemia and the resultant collapse of the erectile tissue. 

ATROPHIC RHINITIS 

Synonyms. — Chronic dry rhinitis; simple mucous rhinitis; muco- 
purulent rhinitis; ozena. 

Definition. — Atrophic rhinitis is characterized by a sclerotic change 
in the mucous membrane and occasionally of the underlying bone and 
by the presence of crusts and an offensive nasal breath. The conditions 
giving rise to these phenomena are varied and often complex. 

Etiology. — The three causes of this condition are as follows : 

(a) A simple atrophic process which is not dependent upon other 
local diseases of the mucous membrane. Meissner holds that atrophic 
ozena (see below) is due to a primitive or broad, shallow nose, and to a 
congenital development of pavement epithelium instead of the columnar 
or mucus-producing variety. 

(b) Pressure necrosis due to excessive distention of the bloodvessels. 
This is a cyanotic congestion due to a heart lesion, and the general venous 
circulatory system participates in the sluggish venous flow. The mucosa 
covering the vessels is kept constantly stretched, and pressure atrophy 
results, as in red atrophy of the liver (D. Braden Kyle). 

(c) Sclerotic atrophy due to a preexisting inflammation of the sinuses 
during which there is an excessive proliferation of connective- tissue cells. 
These after a time become fibrous tissue and gradually cut off the blood 
supply and choke out the glandular and vascular structures of the 
membrane. The nutrition of the mucous membrane is diminished, and 
functional activity is diminished or destroyed. 

These and various other theories are thought to be the cause, or causes 
of atrophic rhinitis. None of them is definitely proved, although the 



ATROPHIC RHINITIS 155 

one (c) advocated recently by Griinwald, and by Vieussens, Reininger, 
and Guns at the end of the seventeenth century, has rapidly gained 
ground in popular opinion. Those who hold to this theory believe that 
all or nearly all cases of atrophic rhinitis are due to suppuration of the 
accessory sinuses of the nose, more especially the ethmoidal and sphe- 
noidal. My own experience is in accord with this view. I have seen 
many cases cured or greatly relieved by attention to the accessory sinuses. 
The ozena is invariably influenced favorably. In conjunction with Dr. 
Joseph C. Beck I have had skiagraphs of the sinuses made in cases of 
atrophic rhinitis, and without exception the sinuses appear cloudy, as 
they do in sinuitis, i. e., their outline is poorly defined and the area of 
the cavities is opaque. This shows that in atrophic rhinitis the sinuses 
are often diseased, though it does not prove the disease of the sinus to be 
primary. 

(a) Simple Atrophic Rhinitis. — Simple atrophy may take place in the 
nasal mucous membrane as well as in mucous membranes elsewhere in 
the body. 

Etiology. — The etiology is not clear, but it is probable that the disease 
is due to the presence of some irritant in the blood, as in syphilis, 
tuberculosis, scrofula, etc. At any rate, the trophic nervous system is 
involved and nutrition modified. 

Treatment. — The treatment should be addressed to the constitutional 
dyscrasia, upon the disappearance of which the atrophic and ozenic 
processes improve or disappear. 

(b) Atrophic Rhinitis Due to Pressure (Cyanotic Engorgement). — 
Etiology. — (a) There may be some lesion of the heart, kidneys, liver, 
or lungs which causes a damming back of the venous blood upon the 
nasal mucous membrane, as well as elsewhere in the body. (6) The 
organs thus affected do not eliminate the waste products as rapidly 
as they should, and these are retained in the blood, where they act as 
irritants, and excite a slight inflammatory reaction. These two factors 
account for the phenomenon known as pressure atrophy as it occurs 
in the nasal mucosa. 

Symptom's. — Although there is true atrophy, the membrane is con- 
gested to such a degree that there is nasal stenosis. The mucosa of the 
nose is swollen, purplish red in color, and inflamed. The ozenic odor 
may be slight. There is an exudation from the engorged vessels, but it 
is not a true mucous secretion. The skin of the nose may be red. There 
is a sense of fulness across the bridge of the nose, and frontal headache 
is commonly present. The conjunctiva may be injected, and this is 
attended by an overflow of tears. 

D. Braden Kyle refers to a case due to organic mitral lesion. I have 
seen a case of this character in which the whole mucosa of the upper 
respiratory tract was cyanotic; the tonsils were enlarged and markedly 
blue from cyanotic congestion. 

Prognosis. — This depends upon the curability of the lesions giving rise 
to the cyanotic congestion. In the cases referred to the patient had a 
valvular heart lesion. 

It is obvious that the treatment in such cases must be palliative only. 



156 THE NOSE AND ACCESSORY SINUSES 

(c) Atrophic Rhinitis Due to Suppurative Sinuitis. — Etiology. — All the 
causes given under the various types of catarrhal rhinitis may act as 
causes of this type of disease. The inflammation attending them is 
followed by a deposit of connective-tissue cells, which, after they become 
organized, cut off the blood supply and choke down the glandular tissue. 
The functional activity is gradually lost and the true mucous elements 
of the membrane finally disappear. The secretions become thick and 
inspissated. They dry upon the surface of the membrane, where, through 
biochemical changes, they develop the ozenic odor. Various theories 
have been advanced in explanation of the cause of the odor. 

The following are suggestive but not conclusive: 

(a) Simple decomposition of the mucopus. 

(b) Degenerative changes in which certain fatty acids are liberated, 
giving rise to the odor. 

(c) The presence of certain bacteria, as the Bacillus fcetidus. 
Ozena a Symptom. — Ozena is not a disease, but a sign of certain 

diseased conditions. It is a "stench," and it is in this sense that the 
term is used. The fetid odor is associated with an inspissated secre- 
tion, which forms greenish crusts over the whole of the nasal mucous 
membrane. Other peculiar conditions may be associated with it, 
especially in those cases in which there is marked atrophy of the mucosa. 
For example, the nose may be broad and flat, the tip somewhat elevated, 
and the blood anemic. The anemia is secondary and not primary as 
in chronic rhinitis with collapse of the erectile tissue. The absorption 
of septic material and the loss of the respiratory functions of the nose 
are probably the chief causes of the anemia. It is a well-recognized fact 
that in mouth breathers from the presence of postnasal adenoids there 
is anemia, which is quickly cured after the removal of the adenoids. 

The mucous membrane becomes atrophied in the later stages, and 
after a longer period the secretion and foul odor spontaneously cease 
and leave a comparatively clean but sclerotic membrane. The ozenic 
odor stops spontaneously after a number of years, hence it is a self- 
limited symptom. The mucous membrane, however, is left very much 
damaged. Its histological character and physiological function are 
changed or entirely lost. 

The sclerosis and ozena in this type of atrophic rhinitis is in all 
probability due to a chronic sinuitis, or to other focalized suppurative 
processes, as has been shown by Griinwald in his work on Nasal 
Suppuration. In other words, the atrophy is not primary, but is second- 
ary to a suppurative inflammation of the sinuses. Indeed, nearly all 
cases of atrophic rhinitis probably fall under this category. This sub- 
division of atrophic rhinitis is, therefore, from a clinical standpoint, of 
the greatest importance. 

The rationale of the atrophic process is generally as follows : 

The secretions from the sinuses, more particularly the fronta^, eth- 
moidal, and sphenoidal, flow downward over the nasal membrane, 
where they dry, forming crusts. These undergo decomposition and 
irritate the underlying mucosa. There is, in addition, a mechanical 



ATROPHIC RHINITIS 



157 



irritation from the shrinkage and contact of the crusts with the mucous 
membrane. The biochemical and mechanical irritation thus produced 
cause a proliferation of connective-tissue cells, which, when fully organ- 
ized, contract and choke the normal tissues of the mucous membrane. 
Shrinkage and atrophy progress until the mucous membrane is replaced 
by a sclerotic tissue, devoid of mucous glands and columnar ciliated 
epithelium, pavement epithelium replacing the columnar type. 

During the progress of the atrophic process the ozena is a symptom, 
but after the true mucous membrane is destroyed the mucous secretion 
and ozena disappear. Crust formation and ozena are self-limited pheno- 
mena, many years being required, however, to rid the patient of them. 

Symptoms. — The symptoms vary with the state of advancement 
and activity of the process. The clinical picture presents the features 
shown in the comparative table given below. This is adapted from 
MacDonald's work on Diseases of the Nose. 

Comparative Table of the Symptoms of Atrophic Rhinitis and 
Rhinitis with Collapse 



Chronic Rhinitis with Collapse of the Erectile 
Tissue. 

1. Chiefly in anemic women. The anemia is 

primary. 

2. No peculiarity of physiognomy. 

3. Mucous membrane anemic. 

4. Collapse of erectile tissue; no tendency to 

atrophy. 

5. No ulceration. 

6. Always bilateral, as it is of constitutional 

origin. 

7. Spontaneous cure if the anemia is relieved. 



8. Olfaction not affected. 

9. No characteristic odor. 

10. Little or no incrustation; if present, is lim- 

ited to the anterior third of the middle 
turbinates. 

11. Headache and dizziness absent. 



Atrophic Rhinitis with Sclerosis and Mvcovs 
Secretion. Ozena. 

1. Chiefly in women and children: all subjects 

become anemic. 

2. Small, sunken wide nose with wide nasal 

fossae. 

3. Mucous membrane anemic. 

4. Collapse of the erectile tissue with tendency 

to atrophy. 

5. Sometimes there is ulceration, and necrotic 

bone if the disease is of sinus origin. 

6. Usually bilateral: may be unilateral. 

7. After some years there is a tendency to im- 

provement of the symptoms. The ozenic 
symptoms disappear as the atrophy be- 
comes more complete. 

8. Olfaction is often lost. 

9. Breath typically ozenic. 

10. Crusts are distributed over the entire mu- 

cous membrane. 

11. Frontal headache and dizziness often pres- 

ent. Occipital headache may be present 
when the sphenoidal sinus is involved. 



Treatment. — When seen in the early stage the treatment should 
aim at (a) the removal of the causes of the inflammation that produces 
the sclerotic process, and (b) intranasal cleanliness. 

(a) Removal of the Causes. — The causes of the inflammation are 
numerous. Some have already been considered under acute catarrhal 
hyperplastic rhinitis, chronic suppurative sinuitis, and the congenital 
primitive nose with its pavement epithelium. Other causes are trauma- 
tism, deflections, and other obstructive lesions of the septum. By the 
removal of these predisposing causes of the inflammation, the sclerotic 
process may be modified or stopped altogether. 



158 THE NOSE AND ACCESSORY SINUSES 

From the foregoing statements concerning focal suppuration within 
the sinuses and elsewhere in the nasal chambers, it is evident that in 
many cases the treatment should be addressed toward the cure of the 
suppuration of the sinuses, rather than to the atrophy resulting from it. 

(5) Intranasal Cleanliness. — Intranasal cleanliness is obtained by the 
use of antiseptic douches containing a liberal amount of mild alkalies 
to soften and dissolve the crusts and tenacious mucopus. A solution 
of 8 grains of sodium bicarbonate to the ounce of water as hot as can be 
borne should be forcibly injected into the nostrils at frequent intervals 
during the day. A fountain syringe is well adapted for this purpose. 
The patient should be instructed to clear the nose by blowing after 
each injection. The injection may be administered by the physician 
at first, as the patient will not or cannot thoroughly cleanse his nose. 
To free the nostrils from crusts and tenacious mucus, a warm antiseptic 
aqueous solution of borax, sodium bicarbonate, oil of eucalyptus, carbolic 
acid, glycerin, and alcohol should be injected into the nostrils. A two- 
ounce hard rubber or an Alpha and Omega bulb syringe is well adapted 
for this purpose, as considerable force is necessary to dislodge the crusts. 

Personally, I prefer to pack the nose with cotton-wool saturated with 
a 10 per cent, aqueous solution of ichthyol, which should be removed 
in from twenty to thirty minutes. The crusts, being softened, are easily 
detached by blowing the nose or by the use of a cotton-wound probe. 
This course of treatment, if faithfully carried out, will afford great 
relief. Mild astringent stimulating solutions, or powders, are of value 
in reducing the local infection. A powder containing 5 to 20 per cent, 
of silver nitrate, or a 1 to 2000 trichloracetic acid solution may be used 
for this purpose. The associated sinus disease should be treated as 
described under the Accessory Sinuses. Indeed, this is often the only 
method of treatment attended with success. Even this fails if the 
atrophy is far advanced. 

Paraffin Injections in Atrophic Rhinitis. — Paraffin injections beneath 
the mucous membrane of the inferior turbinated body and of the septum 
have been used with great improvement of the symptoms. The crusts 
are either diminished or disappear altogether. Some writers recommend 
the use of paraffin in melted form, although the danger of thrombosis 
is ever present. More recently paraffin has been used in solid form 
in order to obviate this danger. A special syringe, adapted to the use 
of semisolid paraffin, has been devised by Dr. J. C. Beck for this pur- 
pose. With this device the danger of thrombosis is reduced to the 
minimum. 

The injections should be made under local anesthesia. The amount 
injected at each sitting varies with the friability of the mucous mem- 
brane. In some cases only one or two minims or grains should be 
injected, a larger amount being liable to tear the mucous membrane. 
In other cases as much as one to two drams may be injected (Fig. 123). 
The injections should be made at intervals of from five to ten days, 
enough time being allowed between the sittings for the subsidence of 
the reaction. 



ATROPHIC RHINITIS, 



159 



Either the inferior turbinal (nasal concha) or the septum may. be 
chosen for the site of the injections. The needle should be introduced 
a half-inch or more beneath the mucoperiosteum and a small amount 
of paraffin injected. It should then be withdrawn, a quarter of an inch 
and more paraffin injected, and so on until the needle is removed. 

The effects produced are a lessening or the disappearance of the crusts, 
a thinning of the secretions, a sense of air passing through the nasal 
chambers, and occasionally edema of the eyelids. The good effects 
have remained for a period of two years and the indications are that they 
may last much longer. The lumen of the nasal chambers is diminished, 

Fig. 123 




Fig. 123. 



p, paraffin injected beneath the mucosa of the septum and the inferior turbinated 
body in atrophic rhinitis. 



thus accounting in a measure for the lessened desiccation of the secre- 
tions. It is also quite probable that the irritation of the paraffin, a 
foreign body in the tissues, produces increased hyperemia and leuko- 
cytosis. Whatever the explanation may be, it appears that paraffin 
injections beneath the mucoperichondrium of the nasal septum and 
beneath the mucoperiosteum of the inferior turbinate materially improves 
the symptoms in atrophic rhinitis with incrustations. In those cases 
wherein the sinus origin of the suppuration and crusts is in doubt, and 
wherein the patient refuses operative interference on the sinuses when 
they are known to be the focal centre of the disease, paraffin injections 



160 THE NOSE AND ACCESSORY SINUSES 

may be used with the reasonable assurance of an improvement of the 
symptoms, though a cure may not result. 



SUPPURATIVE RHINITIS; NASAL SUPPURATION. 

(A symptom, not a primary disease.) 

Suppurative rhinitis has been described by various authors, notably 
by Bosworth in his work on the Diseases of the Nose and Throat. He 
described suppurative rhinitis in children as a primary disease, which, 
when neglected, results in atrophic rhinitis in adults. The trend of 
opinion is gradually relinquishing the view that primary suppuration 
of the nasal mucous membrane is often found. On the contrary, it is 
believed that it rarely exists except secondarily to sinuitis. Personally, 
I hold the latter view. 

Pus in the nasal chambers is present in the later stages of acute coryza, 
which is an infectious disease and is usually complicated by a purulent 
infection of the sinuses. Purulent secretions may also accompany 
syphilitic, tuberculous, and gonorrheal processes in the nose. The 
specific exanthematous fevers are characterized by a purulent inflam- 
mation of the nasal and accessory sinus membranes. The various 
accessory sinuses, when affected by a purulent inflammatory process, 
discharge their purulent secretions into the nasal passages. Generally 
speaking, if after the nasal chambers are cleared of pus by mopping with 
a cotton-wound applicator the pus reappears within a few minutes in the 
middle meatus, it comes from the sinuses discharging into this meatus, 
namely, the frontal, anterior ethmoidal (including the bulla ethmoidalis), 
and the sinus maxillaris (antrum of Highmore). Occasionally one of 
the anterior ethmoidal cells discharges through the inner or median wall 
of the middle turbinate into the olfactory fissure or superior meatus. 
When the pus appears in the superior meatus, it is probably from the 
sinuses opening into the meatus, namely, the posterior ethmoidal and the 
sphenoidal sinuses. An occasional exception to this is when the sinus 
maxillaris (antrum of Highmore), the posterior and superior median 
wall of which is in relation to the superior meatus, discharges through a 
perforation into the superior meatus. Such a condition is rare, hence pus 
in this meatus as seen in the olfactory fissure is generally indicative of 
suppuration of the posterior ethmoidal and the sphenoidal sinuses. It 
is barely possible that there may be a focalized ulceration of the nasal 
mucous membrane in the superior meatus, and that the pus is from the 
meatus rather than the sinuses. It appears, therefore, that nasal suppura- 
tion is rarely, if ever, a primary disease, but that it is always, or nearly 
always, secondary to some other disease of the mucous membrane and 
bony walls of the nasal chambers or the accessory sinuses of the nose. 
Suppuration of the nose as a primary disease will not, therefore, be 
described, but the other diseases to which it is secondary are described, 
and the reader is referred to them for further information. 



PLATE II 




/ ' '.■/ v \ 

I // ' ^ ;> 

i i i ' / 

/ I ! v / 




Anterior Reconstruction. (H. W. Loeb.) 



On account of the multiplicity of lines, the individual ethmoidal cells are not shown; however, 
the two groups are represented, the anterior being lined horizontally and the posterior perpendicu- 
larly. The left sphenoidal sinus lies far above the right; its inner wall extends almost as far to 
the right as the outer wall of the right sphenoidal sinus. 



PLATE III 




V ^ 



Left Lateral Reconstruction. (H. W. Loeb. 



In this and Plate II the frontal sinus is colored yellow, the maxillary purple, the sphenoid green, 
and the ethmoid red, the anterior group being lined horizontally and the posterior group perpen- 
dicularly. The ethmoidal cells are to be noted in two groups, the anterior two in number, and 
the posterior three. The first anterior cell is shown displacing the anterior wall of the frontal. 
The frontal is seen opening into the frontonasal canal. The anteroinferior wall of the second 
ethmoid constitutes the bulla ethmoidalis. 



PLATE IV 



Fig. 1 



Fig. 2 





Large right frontal and a small left frontal sinus. 
(From author's skiagraph.) 



Absence of the frontal sinuses in a patient 
aged twenty-nine years. Small anterior eth- 
moidal cells are shown. This patient had exten- 
sive necrosis of the ethmoidal and sphenoidal 
bones, and secondary mastoiditis complicated by 
a brain abscess in the motor area for the arm 
and leg. The arm and leg on the opposite side 
were partly paralyzed. The ethmoidal and sphe- 
noidal sinuses, mastoid and brain abscess were 
successively operated upon without result. 
(Author's case.) 



Fig. 3 



Fig. 4 




Very large frontal sinuses. (From author's 
skiagraph.) 




Very large irregular right frontal and a small left 
frontal sinus. (From author's skiagraph.) 



The Distribution of the Frontal Sinuses as Shown by 

Skiagraphy. 



PLATE V 



Fig. 1 



Fig. 2 





Large frontal sinuses and an anterior ethmoidal 
cell extending well over the right orbit. (From 
author's skiagraph.) 



Narrow longitudinal frontal sinuses, the right 
having an ethmoidal cell encroaching upon its 
floor. (From author's skiagraph.) 



Fig. 3 





Very large left frontal sinus, almost divided by 
a septum. The left sinus extends about one-half 
inch beyond the median line. (From author's 
skiagraph.) 



Large right frontal sinus with an anterior eth- 
moidal cell (bulla frontalis) encroaching upon its 
floor. (From author's skiagraph.) 



The Distribution of the Frontal Sinuses as Shown by 

Skiagraphy. 



PLATE VI 



Fig. 1 



Fir,. 2 





Side view of frontal sinus with great depth and 
upward extension. A small anterior ethmoidal 
cell, the bulla frontalis, encroaches upon its floor. 
(From author's skiagraph.) 



Another large frontal sinus with marked back- 
ward extension over the orbit. (From author's 
skiagraph.) 



Fig. 3 



Fig. 4 





Side view o. the frontal sinus with limited up- 
ward extension and moderate backward extension. 
(From author's skiagraph.) 



An unusual downward extension of the frontal 
sinus. (From author's skiagraph.) 



The Anteroposterior Extension of the Frontal Sinuses as 
Shown by Skiagraphy. 



PLATE VII 



Fig. 1 



Fig. 2 





Frontal sinus with extreme extension backward, Side view showing absence of the frontal sinuses 

and with a large anterior ethmoidal cell encroaching in a patient aged twenty-nine years. Anterior 

upon the posterior portion of its floor. (From view shown in Plate IV, Fig. 2. (From author's 

author's skiagraph.) skiagraph.) 



Fig. 3 



Fig. 4 





Side view showing a frontal sinus of moderate 
depth. (From author's skiagraph.) 



An extremely large and deep frontal sinus. (From 
author's skiagraph.) 



The Anteroposterior Extension of the Frontal Sinuses as 
Shown by Skiagraphy. 



CHAPTEE IX 

THE INDIVIDUAL SINUSES 

The sinuses are divided for clinical purposes into two groups, namely? 
the anterior and the posterior sinuses. The anterior group is composed 
of the frontal, the anterior ethmoidal, and the maxillary sinuses. Hajek 
calls this group Series I. The posterior group is composed of the 
posterior ethmoidal and the sphenoidal sinuses, and is called Series II. 

Our knowledge of the etiology, symptomatology, pathology, and sur- 
gical treatment of the sinuses has increased so greatly during the last 
ten years that it seems proper to depart from the traditional manner 
of presenting this subject, wherein each sinus is separately described 
and treated. As a matter of fact, a single sinus is rarely diseased, two 
or more being commonly affected at the same time. Indeed, it is not 
uncommon to find all the sinuses on one side of the head affected. The 
maxillary sinus is perhaps more often affected singly than either of the 
other sinuses. This is accounted for by the fact that in about one-half 
of the cases it is infected from the teeth rather than from the nose, whereas 
the other sinuses are nearly always infected from the nose. Having a 
common source of infection, they are, therefore, more often simultane- 
ously diseased. 

For this reason a general discussion of inflammation of the sinuses is to 
be preferred to a discussion of each sinus individually. Nevertheless, it 
will be advantageous to present the peculiar symptoms and other con- 
siderations of each sinus separately. The following considerations are 
therefore to be read in conjunction with the general description which 
follows. 

SERIES I 

Frontal Sinus. — The frontal sinus is an extension upward of the 
ethmoidal cells between the plates of the frontal bone. The extension 
occurs at about the age of puberty, hence in infants and young children 
the frontal sinuses are absent. The size and shape of the frontal sinuses 
vary greatly in different individuals, and indeed the two sinuses often 
vary greatly in the same individual. References to Plates II, III, IV, V 
VI, and VII show some variations in the frontal sinuses, the drawings 
being taken from skiagraphs of some of the author's cases. These 
variations are of surgical interest, as the difference in size will often 
determine the method of operating. If there is a large and deep frontal 
sinus, great external deformity may follow the complete removal of the 
anterior wall. In such a subject the operation may be so executed as 
to avoid, or to greatly reduce, the probability of marked disfigurement. 
11 (161) 



162 



THE NOSE AND ACCESSORY SINUSES 



H. W. Loeb's projections of the sinuses (Plate II and III) show more 
clearly than any other work the relations of the sinuses to one another 
and to the structures of the nose. The anteroposterior and lateral pro- 
jections are shown. Plates IV, V, VI and VII also give a good idea of 
the distribution of the sinuses. 

Skiagraphy. — The skiagraphic plate, if the exposure is properly made, 
affords good information concerning the presence or absence of dis- 
ease in all except the sphenoidal sinus. It is not yet known what causes 
the cloudy appearance when the sinus is diseased. Coakley says it is 
not known whether it is due to the thickness of the inflamed membrane, 
to the presence of pus, or to the changed condition of the bone. I have 
a skiagraph of a patient affected with a severe chronic catarrhal sinuitis 
upon whom I performed a double Killian operation, in which the right 



Fig. 124 




The correct method of making pressure under the floor of the frontal sinus. Pressure is often 
made under the supra-orbital ridge, whereas it should be made much deeper. 



frontal sinus as shown by the plate was cloudy, but less so than the left. 
Upon operating the right sinus was found to be free of pus, and its 
periosteum and mucous membrane were entirely gone. The bone was 
chalky white and slightly roughened. The left sinus was free of pus, 
but was filled with granulation tissue and viscid mucous secretion. 
The patient had complained for several months of an acrid secretion 
which irritated the nasal mucosa. This case is cited here, as it is unique^ 
and demonstrates that a frontal sinus devoid of membrane periosteum, 
and purulent secretion gave a cloudy effect in the skiagraph, though not 
so pronounced as that given by the sinus in which the membrane and 
granulations were present. Pus was not present in either sinus. 

Tenderness upon Pressure. — Tenderness over the frontal bone is rarely 
present in frontal sinuitis except in very acute cases with obstructed 
drainage. Tenderness is often present, however, when pressure is made 



THE INDIVIDUAL SINUSES 163 

against the floor of the affected sinus near the inner angle of the orbital 
cavity (Fig. 124). The finger tip should be placed well under the roof 
of the orbit and the pressure directed upward. Pain is thus often elicited 
even in chronic catarrhal cases. Tenderness in this region does not, 
however, always indicate disease of the frontal sinus, as the anterior 
ethmoidal cells sometimes project beneath the floor of the sinus. 

When such an anatomical deviation is present the surgeon may be 
led to a wrong conclusion. This difficulty may be obviated by having a 
skiagraph made, as it will aid in determining the position and condition 
of the frontal and anterior ethmoidal cells. 

The tenderness present in frontal sinuitis is so nearly in the same posi- 
tion as that in ethmoidal sinuitis that a careful distinction should be made. 
In ethmoidal sinuitis the tenderness is usually located a little above the 
median palpebral commissure (inner canthus) of the eye and a little 
deeper in the orbital cavity than the canthus. The pressure should be 
made inward toward the median line, rather than upward, as in testing 
the frontal sinus. 

Redness and Swelling. — Redness and swelling over the frontal region 
are only present in severe acute inflammation of the frontal sinus where 
the bone is affected by an infective osteomyelitis and the skin has yielded 
to the inflammatory process. There are perhaps a hundred cases of 
frontal sinuitis in which the redness and swelling are absent to one in 
which they are present. The day is past when a surgeon should wait 
for such symptoms before deciding to operate upon the frontal sinus. 
There are other positive indications of disease of the sinus to guide him 
to a diagnosis and to a choice of the mode of treatment. 

Mucous Discharge. — While catarrhal inflammation of the sinuses is 
generally referred to in text-books, no clear idea of the symptomatology 
and diagnosis is given. The presence of pus in the nose has generally 
been considered an essential requirement in making a diagnosis. I 
have found it almost as easy to diagnosticate sinuitis without pus as with 
it. The symptoms are much the same as those in purulent sinuitis, 
except that pus is absent. The secretion is mucous or seromucous in 
character, and might easily escape observation. The patient often 
complains of a burning sensation in the anterior portion of the nasal 
passages or of fissures or excoriations at the margin of the nostrils as a 
result of the acrid catarrhal discharge. 

Headache. — The patient generally complains of frontal headache 
which is limited to, or originates on, the side affected. The headache 
is often more severe during the night, especially upon awaking while in 
bed, or in the morning, than at other times. It is often confounded with 
eyestrain. Headache due to eyestrain is generally relieved upon closing 
the eyes, especially upon retiring for the night. The headache caused 
by frontal sinuitis (catarrhal or suppurative) is not aggravated by theatre- 
going; whereas if due to eyestrain, it is thereby aggravated. 

Dizziness; Vertigo .^Dizziness or vertigo of slight degree is present 
in most cases, severe in others. It is often present in simple catarrhal 
inflammation, as well as in suppurative inflammation of the frontal and 



164 THE NOSE AND ACCESSORY SINUSES 

ethmoidal sinuses. It is especially aggravated by stooping, or, if in a 
stooping posture, upon assuming the erect posture. Careful inquiry is 
often necessary to elicit this symptom, as the patient does not consider 
it of any significance. 

Ocular Symptoms. — According to Fish, Zeim, Wood, Stucky, Coffin, and 
others (Eye in Relation to the Sinuses), inflammation of the frontal or 
any other sinus may give rise to morbid processes in any of the structures 
of the eve. This is accounted for by the free anastomosis of the veins of 
the sinuses with the ophthalmic vein. Congestion in the sinuses causes 
a like condition in the eye. Infection and toxemia are thereby favored; 
papillitis, choroiditis, optic neuritis, iritis, keratitis, etc., thus becoming 
established. 

Intracranial Complications. — Extradural and brain abscess, meningitis, 
and sinus thrombosis may arise from sinuitis. Inasmuch as the posterior 
wall of the frontal sinus is thinner than the external or anterior wall, it is 
curious that intracranial complications are so rare. The superior, longi- 
tudinal, and the cavernous sinus occasionally become thrombosed in 
frontal sinuitis. Meningitis, which has its origin in the sinuses, is more 
frequently reported now than formerly, a fact significant of a better 
understanding of the subject. 

Anterior Ethmoidal Sinuses. — The anterior ethmoidal cells vary 
in number from two to eight, and are smaller than the posterior cells. 
They all drain into the middle meatus. According to Logan Turner, the 
frontonasal canal opened into the infundibulum in about one-half of the 
specimens examined, and directly into the middle meatus in the remain- 
der. The anterior cells are separated from the posterior cells by a thin 
transverse bony partition. The attachment of the middle turbinated body 
to the external wall of the nose also marks the line of division between 
the anterior and the posterior group of cells. The anterior cells lie in 
front of and below it, while the posterior cells lie above and behind it. 
Clinically the two groups of ethmoidal sinuses are, therefore, divided into 
anterior and posterior cells. The anterior cells belong to Series I, while 
the posterior cells belong to Series II. 

Accessory ethmoidal sinuses are sometimes present in the middle 
turbinate and in the uncinate process, and when present drain into the 
middle meatus and belong to the anterior group or Series I. 

The upper wall of the ethmoidal cells is a rather dense but thin plate 
of bone. The cribriform plate is not covered by the cells, but is freely 
exposed in the attic of the nose. While the bone is dense and not easily 
fractured by ordinary force exerted during an operation, its numerous 
openings render it a possible atrium for the conveyance of infection to 
the meninges. The outer wall of the ethmoidal sinuses is the os planum 
or lamina papyracea of the ethmoidal and the lacrymal bones. These 
plates of the bone are extremely thin, and form the inner wall of the 
orbital cavity. Should this plate of bone be perforated, orbital cellulitis, 
with protrusion of the eyeball, might result. In two of my cases orbital 
emphysema followed the ethmoidal operation. 

In Fig. 125 is shown a case of ethmoidal suppuration in which the 



THE INDIVIDUAL SINUSES 



165 



lacrvmal bone was carious and perforated. When first seen there was 
a large nipple-like projection of the skin at the inner angle of the orbit, 
or lateral wall of the nose, in this region The right eyelid was swollen 
and closed, while the left was less swollen and partially closed. The 
upper and lower lids of both eyes were discolored purple. Protrusion of 
the eyeballs was absent, as orbital cellulitis was not present. Had the 
perforation occurred more posteriorly through the os planum, orbital 
cellulitis would in all probability have occurred. 

The patient had a similar attack one year previous to this one. The 
swelling subsided, but the nasal discharge continued, and the eye was 
uncomfortable. 



Fig. 125 



Fig. 126 





Empyema of the ethmoidal sinuses, with 
perforation through the lacrymal plate at the 
inner canthus of the right eye and marked 
bulging at this point. Both upper eyelids are 
edematous and purple. The right eye is en- 
tirely closed, the left almost. One year pre- 
viously had a similar attack following scarlet 
fever. (Author's case.) 



Same case six days after operation. External 
wound gradually filled in by granulation and 
became closed in two months. (Author's case.) 



Skiagraphs showed marked cloudiness in the ethmoidal region on the 
right side, while on the left it was less cloudy. The frontal sinuses were 
absent, or if present were very small. The lower meatus of the nose was 
quite open. Frontal headache and dizziness were prominent symptoms. 

The nipple-like projection was incised at once and discharged a half- 
ounce of thick yellow pus. On the following day, under general anes- 
thesia, the region was exposed by an external skin incision extending 
from a point below the nipple-like tumefaction to the middle of the right 
eyebrow. The lacrymal bone was almost entirely destroyed by necrosis. 
The frontal process of the maxilla was removed with rongeur forceps, 
thus fully exposing the anterior ethmoidal cells to operative interference 
The entire ethmoidal labyrinth, including the middle turbinate, was 



166 



THE NOSE AND ACCESSORY SINUSES 



removed. A curette (Fig. 127) was also used through the anterior 
nasal opening, to make sure that no remnants of the cells were left. 
The cranial plate and the os planum were carefully but thoroughly 
curetted until they were smooth. 

The left side was operated on through the nose, the middle turbinate 
and the ethmoidal cells being removed in their entirety, in so far as they 
could be reached with the curette by this route. 



Fig. 127 



The author's ethmoid curette. 



Fig. 128 



Fig. 126 shows the patient one week after operation. The edema and 
discoloration of the eyelids had entirely disappeared, and the wound 
in the lacrvmal region on the right side permitted a clear view of the 

interior of the nose. The marked change 
in the facial expression is suggestive of the 
improved condition of the patient. 

The Maxillary Sinus (Antrum of High- 
more). — The maxillary sinus, the third and 
last sinus belonging to Series I, is the largest, 
and, according to the prevailing opinion, is 
more frequently diseased than either of the 
other sinuses in both series. Personally, I 
question this statement, as according to my 
own observations the ethmoidal and frontal 
sinuses are more frequently involved. ' Our 
knowledge of the symptomatology of disease 
of the sinuses in general has greatly increased 
during the past five or ten years, with the 
result that ethmoidal, sphenoidal, and frontal 
sinuitis are diagnosticated twenty times as 
often as they were ten years ago. While 
the antrum is still a frequent seat of disease, 
the ethmoidal and the frontal sinus occupy 
a more important place. The diagnosis of 
antral inflammation has been understood for 
many years, and this has given rise to the 
impression that it is much more common than 
inflammation in the other sinuses. It may 
be infected from the nose or the teeth, the 
cases probably being about equally divided 
between these two sources of infection. On 
account of the dental origin of so many cases 
of maxillary sinuitis, it is more often affected singly than either of the 
other sinuses, in which the infection is almost always of nasal origin. 




Showing the thin orbito-eth- 
moidal wall partially destroyed. 
During ethmoiditis this wall may 
be broken or perforated, and give 
rise to orbital cellulitis. (Author's 
specimen.) 



THE INDIVIDUAL SINUSES 167 

When the infection is of nasal origin, quite naturally more than one 
group of sinuses is simultaneously affected. 

The ostium maxillare is situated in the upper portion of the naso- 
antral wall as far removed from the floor of the sinus as possible. This 
apparently renders the drainage of the secretions quite difficult or impos- 
sible, except as they overflow when the antrum is filled. This is not the 
case, however, as there is but little secretion in the sinus in health — only 
enough to keep the mucous membrane moist. The epithelium of the 
antral mucous membrane is of the modified ciliated columnar variety, 
though it is but slightly developed and in patches. The wave-like motion 
of the cilia? aids in carrying the scanty secretions to the ostium maxillare 
at the top of the sinus, where it is discharged through the infundibulum 
into the middle meatus. 

In the course of severe or long-continued inflammation of the mucous 
membrane of the antrum, the cilise are injured or destroyed, and the 
secretions are retained in the antrum because they are not carried to the 
ostium maxillare. The secretions are greatly increased in quantity, a 
fact which still further tends to promote the accumulation within the 
sinus. 

The second bicuspid and the first and second molar teeth are in close 
relation to the floor of the sinus. Indeed, they sometimes project into 
the bony cavity, being only covered by mucous membrane. A suppura- 
tive process around the root of either of these teeth might easily affect 
the mucous membrane of the sinus through the lymphatics and blood- 
vessels. Indeed, an infection of the crown of the teeth may extend 
through the lymphatics to the antrum. 

The superior wall or roof of the sinus is crossed in its central portion 
by the infra-orbital nerve, which lies in a groove on the broad inferior 
side of the plate of bone. It is covered by mucous membrane, and may 
be easily injured during the curettement of the sinus. 

As it is a nerve of sensation rather than of motion, it regenerates 
readily after being injured, even if long portions of it are removed. Motor 
nerves do not thus readily repair. 

SERIES II 

Series II is composed of the posterior ethmoidal and the sphenoidal 
sinuses, and their ostei open into the superior meatus of the nose. 

Posterior Ethmoidal Sinuses. — The posterior ethmoidal are usually 
fewer in number and larger in size than the anterior ethmoidal cells. 
Sometimes they occupy nearly all the ethmoidal labyrinth, extending 
to the anterior portion of the nose, and sometimes the anterior cells 
extend backward almost to the sphenoidal bone. 

The ostia open into the posterior portion of the superior meatus and 
drain upon the posterior half of the middle nasal concha (turbinated 
body). As the middle turbinate slopes slightly downward and backward, 
the secretion flows toward the posterior choana, though it also flows 
over the median border of the turbinate through the olfactory fissure or 



168 THE NOSE AND ACCESSORY SINUSES 

space between the turbinate and the septum, hence a purulent secretion 
in the olfactory fissure is usually indicative of posterior ethmoidal suppu- 
ration. It may, however, indicate sphenoidal disease, or a combined 
empyema of the ethmoidal and sphenoidal sinuses. The secretions may 
also be forced into this position from the middle meatus by snuffling the 
nose. 

The ostia of the posterior cells are not visible by either anterior or 
posterior rhinoscopy, nor are they accessible to the probe or cannula. 

The symptoms of posterior ethmoidal suppuration are not so distinct 
as those in either of the cells comprising Series I. As the posterior 
cells are deeply situated, external tenderness is not present. Exoph- 
thalmos may result from the retention of the purulent secretion in the 
cells, the os planum forced outward behind the eyeball, causing it to 
protrude forward. This also gives rise to diplopia and strabismus and 
to a circumscribed visual field, especially for colors. The ocular dis- 
turbances are extremely rare in proportion to the number of cases in 
which the posterior ethmoidal cells are diseased. According to my 
own clinical observations, the ethmoidal sinuses (anterior and posterior) 
are more often diseased than the maxillary sinus, which is generally 
regarded as the most frequently affected. The ethmoidal sinuses are 
so situated in the upper and narrow portion of the nasal chambers that 
a moderate deviation of the septum or an enlargement of the middle 
turbinate closes the olfactory fissure and thus blocks ventilation and 
drainage of the superior meatus and accessory cells. For these reasons 
the posterior ethmoidal cells are often the seat of disease. 

The secretion in the posterior portion of the olfactory fissure is sig- 
nificant of ethmoidal suppuration, though the pus may come from the 
sphenoid. Indeed, the posterior ethmoidal and sphenoidal cells are so 
closely associated that when one is diseased both are often affected. A 
postrhinoscopic examination showing purulent secretion on top of the 
middle turbinate is almost certain evidence of disease of the posterior 
ethmoidal and sphenoidal cells. Crusts and secretions in the vault of the 
epipharynx are likewise indicative of the same affection. 

Sphenoidal Sinus. — The ostium sphenoidale is situated in the ante- 
rior wall of the sphenoidal sinus near the top of the cavity, though it is 
occasionally a little lower down. It is near the septum of the nose and 
is hidden from view by the close approximation of the middle turbinate 
to the septum. If there is marked atrophy of the turbinate, or if the sep- 
tum deviates to the opposite side, it may be seen by anterior rhinoscopy. 
The opening varies from J to 4 mm. in diameter. 

The purulent secretion flowing from the ostium either drains directly 
through the posterior choana into the epipharynx or on to the posterior 
end of the middle turbinate. Ocular inspection can usually only be 
made after the removal of the entire middle turbinated body. 

The pain or headache occurring in sphenoidal inflammation is usually 
felt in the occipital region on the affected side, though in some cases 
it is diffused and ill defined. Catarrhal inflammation causes the same 
headache as suppurative inflammation, though it may not be so severe. 



DIFFERENTIAL DIAGNOSIS 169 

The ocular symptoms usually ascribed to suppuration of the sphe- 
noidal sinus are those dependent upon the compression of the optic 
and oculomotor nerves. The optic nerve passes over the roof of the 
sinus, hence in closed empyema in which the thin bony wall of the roof is 
softened, compression or even destruction of the optic nerve may take 
place. Optic neuritis may be followed by atrophy and blindness. Optic 
neuritis may be toxic in origin, the noxa originating in the infected 
sinuses. I have seen several cases of neuritis and" blindness which were 
apparently of toxic origin, as there was no retention of secretion. If the 
pressure reaches the sphenoidal fissure, the oculomotor nerves, the third, 
fourth, and sixth, become involved and strabismus in some form follows. 
Intense neuralgia may result from a neuritis of the ophthalmic division of 
the fifth nerve. 

Other ocular lesions arising in the course of inflammatory diseases of 
this and all the other sinuses are referred to in the paragraph on the 
Eve in Relation to the Sinuses. 



DIFFERENTIAL DIAGNOSIS 

To illustrate the methods of differential diagnosis, a series of hypo- 
thetical cases will be given, assuming the symptoms characteristic of 
the simple and combined empyemas of the various sinuses in the open, 
closed, and latent forms. 

Simple empyema refers to those cases which are limited to one group 
of cells, as the maxillary sinus, frontal, anterior ethmoidal, posterior 
ethmoidal, or the sphenoidal sinus. 

Open empyema refers to an empyema, either simple or combined, in 
which the ostia are open and permit of drainage and ventilation. 

Closed empyema refers to those cases in which the ostia are closed by 
pathological changes and the secretions are retained and cause pressure. 

Latent empyema refers to those cases in which the ostia are open, but 
the secretion is so slight that it is not demonstrable, except by irrigation 
of the affected sinus. 

The ostia of the sinuses are so situated that they drain into either the 
middle or the superior meatus of the nose. The sinuses situated an- 
teriorly drain into the middle meatus, while those situated posteriorly 
drain into the superior meatus. 

The anterior group, or those draining into the middle meatus, are the 
antrum, the frontal and the anterior ethmoidal cells. These have been 
designated by Hajek as Series I. 

The posterior group, or those draining into the superior meatus, are 
the posterior ethmoidal and the sphenoidal sinuses. These are desig- 
nated as Series II. For the sake of brevity and clearness these terms 
will be continued. Having defined the terms, we are ready to recite a 
series of hypothetical cases, illustrative of the symptoms and procedures 
necessary to arrive at a positive differential diagnosis between empyema 
of the various sinuses or combinations of them. 



170 



THE NOSE AND ACCESSORY SINUSES 



Case I. — (a) Unilateral discharge from the nose. 

(b) No pain. 

(c) Subjective fetid odor. 

(d) There is an ulcer at the root of the second bicuspid tooth on the 
side of the nasal discharge. 

(e) Anterior rhinoscopy shows pus in the middle meatus. 

The conclusion, based upon the above data, is that one or more of the 
anterior group of cells, Series I, is involved. While the ulcerous bicuspid 
suggests the antrum as the sinus most probably affected, it is by no 
means proved nor are the frontal and anterior ethmoidal sinuses known 
to be free. To differentiate still further the focal centre of infection 
the following procedure must be instituted: 

Fig. 129 




Introducing a trocar and cannula into the maxillary antrum beneath the inferior turbinate for 

diagnostic purposes. 



Remove the secretions from the middle meatus with the douche or 
a cotton-wound probe, and place the patient in Escat's position, i. e., 
the head thrown forward with the affected side turned upward to help 
the flow of pus from the antrum. After the patient has remained in this 
position for a few minutes the middle meatus should be reexamined, 
and if pus is found, the antrum is probably involved. This is not ab- 
solutely established, how T ever, as the pus might have come from the 
frontonasal canal. To establish still further the diagnosis, introduce a 
cannula and trocar through the naso-antral wall in the inferior meatus, 
under cocaine anesthesia (Fig. 129), and irrigate the antrum. If pus 
is found the antrum is involved. The diagnosis is not yet complete, 
as it remains to be demonstrated whether the frontal and anterior eth- 
moidal cells are affected. If after thorough irrigation of the antrum pus 
does not reappear in the middle meatus, the probabilities are strongly in 
favor of a simple empyema of the antrum. This is true in view of the fact 
that the flow of pus from the frontal sinus is nearly constant, as its outlet 
when the patient is in a sitting posture is usually in the most dependent 



PLATE VIII 




Transillumination of the Antrum. 
Right side normal, i e., pupillary reflex and crescent of light present. Left side diseased. 



DIFFERENTIAL DIAGNOSIS 171 

portion of the sinus. In this case pus does not reappear in the middle 
meatus for several hours, unless the patient assumes Escat's position, 
hence the condition is probably a simple empyema of the antrum. 

To strengthen the diagnosis still further, transillumination of the antrum 
and frontal sinus should be performed. If the side involved shows 
opacity over the lower eyelid, a non-luminous pupil, and the absence 
of the sense of light with the eyes closed, empyema of the antrum is 
indicated. If, in addition, transillumination of the frontal sinus is 
negative, the diagnosis of a simple empyema is fairly well established. 

The anterior ethmoidal cells are still to be considered. Transillumina- 
tion does not help us here. The bulla ethmoidalis belongs to the anterior 
ethmoidal cells, and if it is enlarged toward the septum, or downward 
against the uncinate process, it is probable that the anterior ethmoidal 
cells are involved. 

If pus is removed by irrigation from the frontal sinus, the case is one 
of combined empyema of Series I. Skiagraphy shows the frontal and 
ethmoidal areas clear while the antrum upon the affected side is cloudy. 

Diagnosis. — Simple, open empyema of the maxillary antrum. 

Case II. — (a) Unilateral discharge of pus from the nose. 

(6) Dull aching pain in the left cheek bone. 

(c) Pus in the middle meatus. 

(d) Slight tenderness over the cheek bone on pressure. 

(e) Case under observation for several days; pus not always found in 
the middle meatus. 

(f) Outer nasal wall on left side bulges toward septum. 

(g) Pus occasionally discharged in great quantities, after which the dull 
ache in the malar region is relieved. 

After performing the procedures described in Case I the purulent 
secretion is excluded from the frontal and anterior ethmoidal cells, and 
is localized in the maxillary antrum. The retention of the purulent 
secretion gives rise to the pain and tenderness over the left cheek bone 
and to the bulging of the outer nasal wall toward the septum. At times 
the pressure of the purulent secretion was great enough to force it either 
through the ostium maxillare or the accessory ostia, which were closed 
by the swollen mucous membrane. The pain caused by the pressure was 
relieved after each spontaneous discharge. 

Diagnosis. — This is a case of simple, closed empyema of the antrum. 

Case III. — (a) No nasal discharge. 

(b) There is a previous history of nasal discharge from the right side. 

(c) Frequent attacks of frontal headache on the right side. 

(d) Mental depression. 

(e) Aprosexia. 

(f) Transillumination of antrum and frontal sinus is negative. 

(g) Pus not present in either the middle meatus or the olfactory slit. 
(h) Irrigation of the sinus through a puncture in the inferior meatus 

(Fig. 129) shows a very small amount of pus. 

(i) Irrigation of the frontal and anterior ethmoidal cells is negative, 
(f) Irrigation of antrum continued until pus disappears. 



172 THE NOSE AND ACCESSORY SINUSES 

(k) Supra-orbital pain, mental depression, and aprosexia disappear. 
(/) Skiagraph shows cloudiness of antral area, while the frontal and 
ethmoidal are clear. 

Diagnosis. — Latent empyema of the maxillary sinus. 
Case IV. — (a) Unilateral nasal discharge. 

(b) Supra-orbital pain and tenderness on percussion. 

(c) Pressure on the roof of the orbit (floor of frontal sinus) elicits pain. 

(d) Pus present in the middle meatus. 

(e) When wiped away it reappears after a few minutes. 

(J) Escat's position of the head has no influence on the flow of pus. 

(g) Lying upon the back checks the flow. 

(h) Frontal headache beginning on the affected side, more marked in 
the morning. 

(i) Dizziness upon stooping. 

(j) Transillumination shows the crescentic light over the lower eyelid, 
the red pupillary reflex, and the sense of light in both eyes with the lids 
closed. 

(k) Transillumination of the frontal sinus seems to show diminished 
luminosity on the affected side, although the difference between the 
two might easily be accounted for by anatomical variations. 

(/) Puncture of maxillary sinus through the inferior meatus negative. 

Fig. 130 




Frontal sinus cannula. 

(m) The cannula (Fig. 130) is introduced into the frontonasal canal 
and irrigation through it brings pus. Pus reappears in the middle 
meatus in a few minutes. 

(?i) Skiagraphs show cloudiness of the frontal sinus, the ethmoidal 
and antrum being clear. 

Diagnosis. — Simple open empyema of the frontal sinus. 

Case V. — (a) Constant nasal discharge on the right side. 

(b) Supra-orbital headache on the right side. 

(c) Tenderness and swelling over the right eyebrow. 

(d) Anterior rhinoscopy; septum deviated to right in the region of 
the middle turbinate. Polypi in the middle meatus on right side. 

(e) Probe shows polypi attached to uncinate process and the middle 
turbinal. 

(f) Provisional diagnosis: Series I involved, probably localized in the 
frontal or the frontal and anterior ethmoidal sinuses. 

(g) Transillumination of maxillary sinus shows faint crescent and 
pupillary reflex. Frontal sinus opaque. 

(h) Polypi removed. 

(i) Maxillary sinus punctured through inferior meatus and odorless 
pus is washed out. 



DIFFERENTIAL DIAGNOSIS 173 

(y) Frontal sinus irrigated through cannula. Pus abundant. 

(k) Frontal sinus irrigated daily, maxillary occasionally; pus absent 
in maxillary after the first irrigation. 

(/) At end of six weeks frontal sinus still discharges pus. 

(m) Radical external operation; caries and polypi found in frontal 
sinus. 

Diagnosis. — Empyema of frontal sinus with secondary involvement of 
the maxillary sinus, which acts as a reservoir, but is not a focal centre 
of disease. 

Case VI. — (a) Patient complains of purulent crusts in the right 
nostril and in the epipharynx on rising. Hawks up crusts from the 
epipharynx. 

(b) Dull headache variously located; sometimes it is frontal, then 
vertexial, and then occipital. 

(c) Mental depression and aprosexia. 

(d) Anterior rhinoscopy; septum deviated to right in region of 
middle turbinal. Olfactory slit narrow and filled with pus and crusts. 
Small polypi springing from above the middle turbinal. 

(e) Posterior rhinoscopy shows purulent secretions flowing over the 
posterior end of the right middle turbinal and the posterior epipharyngeal 
wall. Crusts not found, as they form at night when the position of the 
head and the quietness of sleep favor accumulation. 

(f) Middle meatus free from pus. 

(g) Provisional diagnosis: Empyema of Series II. 

(h) A cannula is passed into the sphenoidal sinus through its ostium. 
Irrigation shows no pus. 

(i) A curved silver probe introduced through the olfactory slit shows 
bare, rough bone in the superior meatus. 

Diagnosis. — Open empyema of the posterior ethmoidal cells. The 
irrigation of the sphenoidal sinus eliminates it from consideration, and 
as Series II is only composed of the sphenoidal and posterior eth- 
moidal sinuses, the empyema is located by exclusion in the posterior 
ethmoidal cells. This is still further substantiated by the presence of 
bare, rough bone in the superior meatus. 

Case VII. — (a) Patient complains of the formation of crusts in the 
epipharynx, also of postnasal "dropping." 

(6) A subjective sense of odor is present, even in the absence of such 
an odor. 

(c) Vertexial and occipital headache. 

(d) Field of vision, especially for colors, diminished. 

(e) Mental depression. 

(/) Anterior rhinoscopy; olfactory slit occasionally filled with pus, 
though it is usually clear. 

(g) Probing shows the mucous membrane of the superior meatus 
intact, while probing of the sphenoid sinus shows roughened bone and 
bleeding. 

(h) Posterior rhinoscopy; purulent secretions on posterior end of right 
middle turbinated body and upon the posterior wall of the epipharynx. 



174 THE NOSE AND ACCESSORY SINUSES 

(i) Irrigation of the sphenoidal sinus shows pus in considerable 
quantities. 

(j) Transillumination of maxillary and frontal sinuses negative. 

(k) Examination of the fundus oculi shows slight papillitis. 

Diagnosis. — Open empyema of Series II, probably focalized in the 
sphenoidal sinus. If the treatment of the sphenoid is followed by the 
disappearance of all symptoms, the diagnosis is positive. If the purulent 
discharge continues, the posterior ethmoidal cells should be removed; 
and if a cure follows, the diagnosis of combined empyema of the sphe- 
noidal and posterior ethmoidal sinuses is established. 

Case VIII. — (a) Intense headache at the vertex and occiput. 

(b) Crust formation and postnasal dropping, yellow in color. 

(c) Subjective sense of odor. 

(d) Sudden blindness in the right eye. 

(e) Great mental depression and aprosexia. 

(f) Dizziness complained of. 

(g) Anterior rhinoscopy shows pus and crusts in the olfactory fissure. 
(h) Transillumination of the maxillary and frontal sinuses is negative. 
(i) Probing of the middle and superior meatuses is negative. 

(j) Cannot locate the ostium of the sphenoid on account of the great 
swelling. 

(k) The middle turbinate is removed and the ostium sphenoidalis is 
filled with granulation tissue bathed in pus. 

(I) The anterior wall of the sphenoid is removed, the cavity curetted, 
and granulation tissue and pus are found in considerable quantities. 

(m) After the removal of the middle nasal concha (turbinated body) 
no pus is seen coming from the region of the posterior ethmoidal cells. 

Diagnosis. — Simple closed empyema, granulations, and caries of the 
walls of the sphenoidal sinus on the right side. 

The sudden blindness may be accounted for by pressure upon and 
inflammation of the optic nerve, or by venous stasis or toxemia. 

Case IX. — (a) Supra-orbital, vertexial, and occipital headache. 

(b) Purulent discharge from the right nostril into the epipharynx. 

(c) Subjective sense of odor. 

(d) Strabismus of the right eye. 

(e) Transillumination shows opacity of the right lower eyelid (left 
negative) and absence of red pupillary reflex, also opacity over the right 
frontal sinus. 

(J) The bulla ethmoidalis is enlarged downward and inward, and 
there are polypi in the middle meatus. 

Provisional diagnosis of empyema of Series I and II is made. It is 
still a question as to the exact localization of the suppuration. It seems 
probable that all the sinuses in Series I and II are involved, although 
this is not yet proved. 

(g) The blunt probe is used, and shows bare rough bone in the superior 
meatus and in the region of the uncinate process (the inner and inferior 
lip of the hiatus semilunaris). This makes it quite probable that the 
posterior ethmoidal, anterior ethmoidal, and the antrum are involved. 



DIFFERENTIAL DIAGNOSIS 175 

When the bulla ethmoidalis is enlarged downward the discharge of 
pus is blocked in the infimdibulum and is pent up in the anterior 
ethmoidal and the frontal sinuses. The pus under these circumstances 
often breaks through the lateral wall of the nose into the antrum. The 
enlargement of the bulla (one of the anterior ethmoidal cells) is in itself 
significant of a diseased process in this group of cells. 

(h) The anterior end of the middle turbinal and the polypi in the 
middle meatus are removed. 

(i) The maxillary sinus is irrigated through a puncture in the inferior 
meatus and much pus removed, but it continues to discharge. 

(y) The frontal sinus is irrigated through a cannula and a copious 
discharge of pus follows and persists. 

(k) The bulla is broken down with a curette, and pus wells from its 
interior. A polypus also protrudes from its cavity. The remainder of 
the middle turbinate is resected and the posterior ethmoidal cells are 
thoroughly removed by curettement. After a time the discharge of pus 
ceases. 

Having demonstrated the persistent presence of pus in all the sinuses 
embraced in Series I and II a positive diagnosis may be made. 

Diagnosis. — Combined empyema of all the accessory nasal sinuses 
of one side of the head. A radical external operation and intranasal 
operations may or may not be indicated. All the sinuses may be drained 
by operative procedures through the nose and a cure effected without 
external operations in many cases. 

Note. — While the foregoing series of hypothetical cases does not 
exhaust the list of possible and actual combinations of empyema of the 
accessory nasal sinuses, it illustrates fairly well the data and methods 
of procedure necessary to arrive at a diagnosis. Nor should it be under- 
stood that the data used in the above series is in strict accord with the 
clinical aspect of every case having the diagnosis given above. Other 
symptoms and pathological conditions are found, and great anatomical 
asymmetry often complicates the diagnosis. W 7 hat is given above is in 
the main true. Much that is left unsaid is also true. It is obvious that 
in a limited number of hypothetical cases all the clinical and pathological 
data cannot be given. 



CHAPTER X 

GENERAL CONSIDERATIONS IN REFERENCE TO THE SINUSES 

The nasal accessory sinuses in man are the residual olfactory organs. 
In his primeval state the acute sense of smell was necessary, as it is in 
some lower animals. In the process of evolution the large distribution 
of the olfactory nerve has become less and less necessary, hence the 
sinuses are being gradually closed off from the nasal chambers until only 
small openings are present in man. Inflammation of the lining mucous 
membrane of the walled-off spaces becomes, therefore, a frequent patho- 
logical process. If the sinuses were open more to ventilation and drain- 
age, inflammatory processes within them would occur less frequently, 
because the perpetuity and destructiveness of the process depend very 
largely upon the lack of normal ventilation and drainage. It follows, 
therefore, that when inflammation of the sinuses is present the first 
principle of treatment is to establish ventilation and drainage. This may 
only mean that the swollen and inflamed mucous membrane around 
the cell openings should be depleted by the application of adrenalin, 
cocaine, or antipyrine, or it may mean that some surgical procedure 
should be instituted for their relief. Whichever may be necessary, venti- 
lation and drainage of the sinuses is of prime importance, and the 
removal of the morbid material is secondary to this. 

Etiology. — The etiology of the inflammatory diseases of the nasal 
accessory sinuses of the nose, like that in other mucous-lined cavities 
of the body, is largely embraced in those conditions which interfere with 
the drainage and ventilation of the cavities. (See Etiology of Inflamma- 
tions of the Nose and Accessory Sinuses, Chapter VI.) When there is 
good drainage and ventilation, inflammation is rare, except in those cases 
subjected to a virulent infection or in which the resistance is lowered by 
some dyscrasia. The local expression of a constitutional dyscrasia, as 
syphilis, tuberculosis, etc., or a carious process in some contiguous organ, 
as a tooth, may cause inflammation of a sinus, even though the drainage 
and ventilation of the cells is "normal. Aside from these and other local 
and constitutional diseases which cause sinuitis, it may be said that 
the anatomical configuration of the interior of the nose, whereby the 
drainage of the secretions and the ventilation of the sinuses are interfered 
with, plays an important role in the etiology of inflammation of the 
sinuses. 

The constitutional diseases having most to do with the causation of 

sinuitis are syphilis and tuberculosis. When there is a granulomatous 

infiltration in the outer wall of the nose, the ulcerative process may 

invade the sinuses and give rise to inflammatory symptoms, as pain, 

(176) 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 177 

tenderness, suppuration, headache, dizziness, etc. Likewise, when 
tuberculous infiltration and subsequent degeneration are focalized in the 
outer wall of the nose, the sinuses may participate in the process, or 
the ostia of the sinuses may become closed from swelling of the mucous 
membrane, and thereby obstruct the drainage and ventilation. 

Diseases of the contiguous anatomical structures, as the teeth, hard 
palate, and outer wall of the nose, may give rise to inflammation of the 
mucous membrane of the sinuses by an extension of these cavities, and 
by blocking the cell openings or the infundibulum, so that drainage 
and ventilation are impaired or altogether lost. 

Caries of the root of a tooth located beneath the floor of the maxillary 
sinus (antrum of Highmore) may cause empyema of the antrum by 
infection through the carious fistula thus formed, or by way of the vessels 
and lymphatics. It has been estimated that nearly one-half of all 
empyemas of the antrum have their origin in diseased teeth, while the 
remainder are due chiefly to intranasal diseases and anatomical deformi- 
ties of the nose. Nasal polyp is also regarded as a cause of sinuitis, 
although I believe the polyp is more often the result than the cause. 
However this may be, it is certain that the presence of a nasal polyp 
aggravates an existing sinuitis, and that its removal is often attended 
by an apparent rather than a real cure of the inflammation. 

Foreign bodies in the nasal passages may cause sinuitis by erosion 
and subsequent infection of the nasal mucosa, by directly blocking 
the cell openings, or by erosion through the outer nasal wall into the 
sinuses. 

Nasal operations may result in sinuitis by reactionary infection and 
inflammation, which may extend directly through the outer nasal wall or 
via the cell openings into the sinuses. In hospital practice particularly, 
infection from other patients may give rise to sinuitis. 

Nasal dressings may cause a damming up of the secretions which 
undergo decomposition and infection, and thus give rise to inflammation 
of the sinuses. Too much emphasis cannot be laid upon the untoward 
results of intranasal tamponing, as it is a fruitful source of inflammatory 
disease of the nasal and sinus mucous membranes. Personally, I have 
abandoned intranasal dressings except in those cases in which there is 
severe hemorrhage, and in which a dressing must be introduced to hold 
the septum in position after certain operations for the correction of 
deviations. Even then they should not be left in position an hour 
longer than is absolutely necessary to accomplish their purpose. 

Venous stasis from intranasal pressure may cause sinuitis. The 
pressure may be due to some anatomical or pathological departure from 
the normal, as a deviation of the septum pressing against the outer wall 
of the nose, or to gummatous swelling of the septum. 

These and other pathological lesions of the adjacent structures may 
cause sinuitis. All cases should, therefore, be carefully studied in order 
to determine the predisposing cause of the inflammation. 

The Exciting Causes. — The exciting causes of inflammation of the 
sinuses are the various microorganisms causing the exanthematous and 
12 



178 THE NOSE AND ACCESSORY SINUSES 

other infectious fevers. It is well known that coryza is often one of the 
early phenomena in this class of cases, and that it is due to micro- 
organisms and their toxins. The inflammation usually extends to the 
sinuses, where it may remain in a latent or chronic form. In some cases 
it is only after many years that the involvement of the sinuses becomes 
obvious enough to attract the attention of either the patient or the 
physician. 

It is probably true that the inflammation thus started is more likely 
to become chronic in those cases in which the cell openings are more 
or less blocked by anatomical deviations of the septum or other obstruc- 
tive lesions of the nose. If, for example, the septum in its upper portion 
is deviated to one side, and lies against the middle turbinate, the sinuitis 
which develops during an attack of one of the infectious fevers is more 
likely to continue into the chronic form than it is where no such obstruc- 
tive deformity of the septum exists. 

Hajek has emphasized the causative relation of influenza to inflam- 
mation of the sinuses. Indeed, he claims that it is probably the most 
frequent source of infection. 

Pathology. — The pathological changes which occur in the mucous 
membrane and bony walls of the sinuses in the course of suppurative 
inflammation are what might be expected in a mucous-lined cavity. 
Much discussion has arisen on this subject between anatomists and 
clinicians. Anatomists have found less marked changes, probably 
because they only examined such cases as came to them from the dead- 
house, while clinicians describe much more extensive changes in living 
cases, from whom specimens were removed during life, or upon the 
postmortem table. I prefer to base the pathology upon the clinical 
rather than upon the anatomical data. 

Acute inflammation of the sinuses may be divided into the exudative 
and the diphtheritic, although the latter is rarely present and is not a 
true diphtheritic membrane. 

The exudative inflammation may be serous, fibrinous, seropurulent 
or purulent in character, according to the intensity of the inflammatory 
process. 

For didactic purposes the changes which occur in the tissues may be 
studied in the following order, which represents the usual sequence of 
the pathological events: 

(a) The submucous tissue is infiltrated with serum, while the surface 
is dry. Leukocytes also fill the meshes of the submucous tissue. 

(b) The capillaries are dilated, and the mucous membrane is red in 
consequence. 

(c) After a few hours, or a day or two, the serum and leukocytes 
escape through the epithelial covering of the mucosa, where they become 
admixed with bacteria, epithelial debris, and mucus. In some instances 
capillary hemorrhage occurs and blood becomes mixed with the secre- 
tions. The secretions, at first thin and watery, later become thicker 
and tenacious, on account of the coagulation of the fibrin of the 
serum. 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 179 

(d) In many cases resolution by the absorption of the exudate and 
the cessation of the discharge of the leukocytes takes place in from ten 
to fourteen days. 

(e) In other cases, however, the inflammation passes from the catarrhal 
to the purulent type, the leukocytes being thrown out in immense numbers. 
Resolution is still possible, although not probable, as the tissue changes 
are not yet of a fixed type. Unless the process is speedily arrested the 
tissue changes become permanent and chronicity is established. 

(f) If the ostia of the sinuses are open the discharge of pus may con- 
tinue indefinitely with little or no pain. If, on the contrary, they are 
closed, the purulent secretion is retained, and pressure symptoms, as 
pain, swelling, and tenderness, arise. If the discharge cannot escape 
through the ostia the point of least resistance bulges before the pressure 
of confined pus. The points of least resistance vary in different cases, 
although there is reasonable constancy in their location. 

The points of least resistance in the sinuses are as follows, due allow- 
ance being made for anatomical variations: 

(a) In the frontal sinus the inferior wall is the thinnest, especially 
three-quarters of an inch from the median line over the anterior ethmoidal 
cells, hence the frequent involvement of these cells in frontal empyema. 
Clinically, we often see cases in which there is a sudden gush of pus into 
the nasal chamber, after which the pain and other pressure symptoms are 
relieved. It is probable that in these cases the floor of the frontal sinus 
yielded to the pressure of the pent-up pus, which may have discharged 
through the anterior ethmoidal cells, though it may have escaped through 
the frontonasal canal. 

(b) In the antrum the most vulnerable point in the nasal walls is 
the pars membranacese, the membranous portion of the middle meatus. 
The anterior and superior walls are sometimes thin, and may bulge, 
or become perforated by the pressure of the retained pus. One of the 
characteristic symptoms of antral empyema is the tenderness and swell- 
ing over the anterior (canine fossa) wall. Bulging of the upper or orbital 
wall causes an interference with the external muscular apparatus of the 
eyeball. Perforation in the orbital wall, or roof of the antrum, gives 
rise to an abscess of the orbit, or orbital cellulitis. 

(c) In the ethmoidal sinuses the point of least resistance is, perhaps, 
difficult to define, on account of the complexity of the ethmoidal laby- 
rinth, it being composed of several pneumatic spaces. The lamina 
papyracese (paper plate) separating the cells from the orbital cavity is 
quite thin, as its name implies, and may be the seat of bulging and 
perforation. The pressure may extend toward the orbit and give rise 
to a lack of balance of the external muscles of the eyeball, strabismus 
being the most common expression. The inner or nasal aspect of the 
ethmoidal cells is more thin, and in empyema may be distended until 
it presses against the septum. 

(d) In the sphenoidal sinus the point of least resistance is in the upper 
wall, or roof, which is in close relationship to the optic nerve; hence, 
the ocular disturbances often found in closed empyema of this sinus. 



180 THE NOSE AND ACCESSORY SINUSES 

In chronic inflammation by far the greater number of observations 
have been made on the antrum, because it is more accessible to inspection 
and operation through the canine fossa. There is no particular reason, 
however, why similar changes may not occur in the other sinuses. I will 
therefore describe in general the pathological changes which occur in the 
entire sinus labyrinth, pointing out the changes peculiar to each group of 
cells, in addition to the changes common to them all. In general, it may 
be said that the pathological changes in the accessory sinuses of the nose 
correspond with the descriptions in general pathology. 

The slighter changes are quite like those in acute suppurative inflam- 
mation affecting other mucous membranes and bone tissue. The mucous 
membrane may present a granular surface, villous and fungoid excres- 
cences, granular, cushion-like thickening, etc. In the older cases there 
is thickening from deposit of hyperplastic and pyogenic membrane 
The membrane may be destroyed in spots by ulceration, exposing 
smooth, bare bone, or it may be soft or rough from caries. In some 
cases necrosis and bone sequestra are present, or they may be ab- 
sorbed. A microscopic examination of the secretions of the mucous 
membrane sometimes shows a loss of the epithelium and glands, which 
are replaced by connective tissue. Ulcerations of the membrane are 
often surrounded by granulation tissue, especially if there is necrosis 
of the bone. Granulation buds may encroach upon the periosteum 
and thus unite the bone and mucous membrane. ^Yhen this happens 
the bone is superficially absorbed and somewhat roughened in conse- 
quence. Osteophytes, or bony scales or plaques, resulting from plastic 
exudation sometimes form on the surface of the bone. 

Polypi have been found in all the sinuses, although they are more 
common in the antrum and ethmoidal cells. They are much more 
common in the ethmoidal cells than is generally supposed. Their hidden 
location within the small ethmoidal spaces render their diagnosis rather 
difficult. In the antrum, however, they are more easily diagnosticated, 
as they may be exposed through the canine fossa. As this sinus is 
quite large, the polypi are easily seen and diagnosticated. They have 
been found in the frontal and sphenoidal sinuses, although not so 
frequently as in the antrum and ethmoidal cells. The polypi in the 
ethmoidal cells are usually quite small, on account of the limited 
space within the cells, whereas in the antrum they are much larger. In 
empyema of the ethmoidal cells the thin lamina papyracese separating 
the cells from the orbital cavity may be perforated or entirely destroyed 
by the suppurative process. The same is true of the cranial plate 
separating the cells from the anterior hemisphere of the brain. In the 
latter case the meninges are exposed to infection, and may be the seat 
of meningitis, brain abscess, or epidural abscess. Such an exposure 
of the meninges may exist in cases of latent ethmoidal empyema, with 
no other symptoms than a slight headache and mental irritability. A 
slight intranasal operation, especially on the middle turbinated body, 
may light up the slumbering fires and rapidly lead to a dangerous, or 
even a fatal, meningitis. The cases of meningitis occurring after intra- 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 181 

nasal operations are probably to be explained in this way, as has been 
shown by Griinwald in his work on Nasal Suppuration. 

Thrombosis of the longitudinal and cavernous sinuses occasionally 
complicates ethmoidal empyema. Retrobulbar suppuration, or orbital 
cellulitis, is a comparatively infrequent complication of ethmoidal 
empyema. 

In frontal empyema the floor and posterior wall are most often the 
seat of destructive changes. The floor near the median line is in apposi- 
tion with the anterior ethmoidal cells and nasal septum, hence the cells 
and septum* are frequently more or less involved in the carious and 
necrotic retrograde changes. The anterior ethmoidal cells are always 
filled with pus in cases of frontal empyema. 

Symptomatology. — The Objective Symptoms. — The objective symp- 
toms may be extranasal or intranasal. 

The extranasal symptoms are those changes in the appearance of the 
skin of the face and of the fundus of the eye as shown by ophthalmo- 
scopic examination. In addition to the objective signs, the results of 
transillumination and of skiagraphy afford important objective infor- 
mation. 

The intranasal objective signs of disease of the sinuses are those 
changes in the appearance of the outer walls of the nasal chambers and 
the location of the secretion as it drains from the affected cells. 

Extranasal Objective Symptoms.— (a) TV hen any of the sinuses con- 
tiguous to the skin of the face are involved (frontal, anterior ethmoidal, 
or antrum) there may be redness, swelling, and heat of the skin covering 
the affected area. If, for instance, the frontal sinus is acutely inflamed 
there may be swelling, redness, and heat of the skin in the frontal region; 
likewise in the malar region in antral disease and at the inner angle 
of the orbit in anterior ethmoidal disease (Fig. 125). Tenderness upon 
pressure (a subjective symptom) is also present when redness and swelling 
are found. 

(b) The fundus of the eye sometimes affords very useful and important 
objective evidence of inflammation. 

(c) Transillumination of the face affords objective information as to 
the condition of the maxillary sinus, and sometimes of the frontal sinus, 
but none in reference to the other sinuses. In transillumination of the 
antrum three points should be noted, namely: (1) The red pupillary 
reflex, (2) the crescent of light corresponding to the position of the 
lower eyelid, and (3) the sense of light in the eye when closed. If the 
red pupillary reflex and the crescent of light are absent the antrum 
is probably affected. Note both sides at once, and thus determine 
which one, if either, is affected. A comparison of the lower portion 
of the field of illumination may be very misleading, as the anterior 
wall of the antrum varies greatly in density, irrespective of the disease 
present. The orbital or upper wall of the antrum is, however, more 
nearly uniform in its density in all cases, and affords a fair opportunity 
for a comparison of the transilluminated light through the two orbital 
plates; that is, when both orbital plates of the antrum are healthy the 



182 THE NOSE AND ACCESSORY SINUSES 

amount of light transmitted through them is about equal; whereas 
when one is thickened by an inflammatory exudate the transmission of 
light is interfered with, hence the crescent of light is dimmed or alto- 
gether absent. Likewise when both orbital plates are healthy (antral 
disease absent) the light transmitted into the interior of the eyeball is 
shown in the red pupillary reflex in each eye ; whereas if one antrum is 
involved the pupillary reflex is absent upon that side and present on 
the other. The sense of light (eyes closed) is present on the healthy side 
and absent upon the diseased side in maxillary diseases. 

Transillumination of the frontal sinuses is an uncertain means of 
diagnosis, as the anterior wall often varies so much in thickness on the 
two sides in the same individual. The hooded lamp should be placed 
under the floor of the frontal sinus at the upper and inner angle of the 
orbit and the two sides compared. Dr. Birkett has devised a double 
lamp (Fig. 131), so that both sides can be illuminated at once, to facilitate 

Fig. 131 




Birkett's transilluminator for the simultaneous illumination of both frontal sinuses. 

comparison. If the lamp is not placed well under the supra-orbital 
ridge the skin transmits the light and may thus lead to a false deduction. 
Taken as a whole, transillumination of the frontal sinuses is not a reliable 
procedure. 

Skiagraphy. — Skiagraphy of the accessory sinuses of the nose should 
be a routine practice when access is had to a competent radiographer. 
Prof. Gustav Killian first practised it in diseases of the nasal accessory 
sinuses. Personally, I have skiagraphs made of all my private sinus 
cases and find them of the greatest diagnostic aid, especially in deter- 
mining the extent of the suppurative involvement. During the past 
year I have had the plates made with first one orbit on the negative, 
and then the other orbit thus placed. These oblique positions give 
perspective views of all the sinuses from the frontal to the sphenoidal, 
and enable the attending surgeon to locate the purulent inflammation 
in one or more of the cells. The great difficulty has been to find a 
radiographer who understands the technique well enough to produce 
clear skiagraphic plates. 



GEXERAL CONSIDERATIONS IN REFERENCE TO SINUSES 183 

To get a plate with clearly defined outlines of the sinuses, and with a 
clear definition of their area, it is necessary so to place the a>ray tube as 
to avoid the heavy bone of the floor of the cranium, as it would interfere 
with the passage of the rays through the head. The x-ray tube should 
be applied, therefore, to the back of the head at a point above the occiput 
and floor of the cranium, as shown by the line A in Fig. 132. If the tube 
is applied at B, the rays would have to pierce through the dense bone 
of the occiput and the long axis of the plate of bone forming the floor of 
the cranium before reaching the frontal and ethmoidal sinuses, thereby 
interfering with the formation of a clear shadow of the dense bone form- 
ing the walls of the sinuses and the production of a clear definition of the 
area of the sinus cavities. If, however, the x-ray tube is applied at A, 
midway between the occiput and the vertex, the rays have an unimpeded 
course of the frontal and ethmoidal sinuses, and the outline and area of 
normal sinuses will be clear and well modulated. The delineation of the 



Fig. 132 




Schema showing the proper position for making a skiagraph of the frontal and ethmoidal sinuses: 
A, the proper angle for passing the x-rays through the head; B, the improper angle, as the rays must 
pass through a great deal of dense bone (Z>) to reach the sinus; C, an 8 x 10 inch photographic 
plate against which the forehead should rest; E, the table upon which the patient lies. The forehead 
should be placed upon a triangular block with an inclination of 25 degrees, as this is more 
comfortable to the patient and renders the line (A) perpendicular to the table. 



maxillary sinuses is not so clear, as the rays must pass through more bone 
tissue to reach it. A clear skiagraph of this sinus is not so essential, as 
this sinus is easily and successfully examined by transillumination with 
an electric lamp in the mouth. 

The advantages derived from skiagraphy of the accessory sinuses in 
diagnosis are: 

(a) If a sinus is healthy, its outline on the plate or negative is clear 
and distinct (light) and its area is clear and dark. If the sinus is diseased, 



184 THE NOSE AND ACCESSORY SINUSES 

its outline is less clear and distinct and its area is cloudy or hazy upon 
the negative or plate. Prints from the plates are rarely satisfactory 
for diagnostic purposes. 

(6) The dimensions of the frontal sinuses are clearly defined, thus 
affording the surgeon positive information as to the extent of exposure 
necessary before he begins an external operation. A skiagraph through 
the lateral dimensions of the head shows the depth of the frontal sinus, 
thus affording the surgeon additional data as to the probable deformity 
to be expected should the Killian operation be performed. The wider 
and deeper the frontal sinus the greater is the deformity following the 
complete removal of the anterior bony wall of the sinus. The information 
gained from the two views of the frontal sinus may cause the operator 
to determine either to select or reject a given method of operating. If, 
for example, the skiagraph shows a small, shallow frontal sinus, the 
Killian operation might be chosen in preference to other methods, as it 
is a thorough and satisfactory method of operating, and would in such a 
case be followed by little or no external deformity. If, on the other hand, 
the plates show a large and deep frontal sinus the surgeon might be 
influenced to adopt some other method of operating which would not be 
attended by such marked external deformity. 

(c) In some instances, when the frontal sinus seems to be involved, 
the skiagraph will show a total absence of disease, and sometimes of 
the sinus, information of no small consequence to both the surgeon and 
the patient. » 

Remark. — According to my observations the skiagraph does not 
differentiate between a catarrhal and a suppurative sinuitis. 

The Intranasal Objective Symptoms. — (a) The contour of the outer 
nasal wall sometimes affords information as to the condition of the 
sinuses. In closed empyema of the antrum the inner wall of the antrum 
may be pushed toward the septum. Likewise in empyema of the bulla 
ethmoidalis its median wall may be distended so as to close the hiatus 
semilunaris, and impinge against the external surface of the middle turbinal. 

(b) The texture of the mucous membrane of the nose, especially that 
portion of it covering the middle turbinated body, is sometimes indicative 
of sinus disease; that is, when the mucosa of the anterior end of the 
middle turbinate is boggy and velvety in texture, it usually signifies the 
existence of an inflammation of the ethmoidal cells. 

(c) Polypi are often associated with disease of the sinuses, and are, I 
believe, usually secondary to the inflammation. 

(d) Pus within the nasal chambers is usually significant of empyema 
of the sinuses. The nasal mucosa is rarely the focal centre of suppurative 
inflammation, whereas the sinuses are commonly the focal centre of such 
an inflammation. The presence of pus in the nasal chambers should, 
therefore, excite suspicion of the existence of an inflammation of the 
sinuses. (To determine which of the sinuses is involved, see General 
Diagnosis.) In a general way it may be stated that pus in the middle 
meatus signifies an involvement of the frontal, anterior ethmoidal, or 
the maxillary sinus, as these cells drain into the middle meatus. If pus 
is seen in the olfactory fissure (between the septum and middle turbinate) 



GEXERAL CONSIDERATIONS IN REFERENCE TO SINUSES 185 

the posterior ethmoidal or the sphenoidal cells are involved, as these 
cells drain into the superior meatus above the middle turbinate. 

Subjective Symptoms. — The subjective symptoms of inflammation of 
the sinuses have reference to the sensations of pain and of pressure, the 
equilibrium of the mind, and the impairment of the special senses. 

(a) Pain referable to the region of the sinus involved may or may 
not be present. In active inflammation of the antral or frontal sinus 
pain is often distinctly referred to the region involved. In the deeper 
sinuses, as the ethmoidal and sphenoidal, the pain is vaguely deep 
seated in the head, or it is referred to the periphery of the head without 
reference to the location of the sinus. For example, sphenoidal inflamma- 
tion may give rise to pain in the occipital or to the frontal region. As a 
matter of fact, inflammation in any or all of the sinuses usually causes 
pain in the frontal region. These pains are almost universally called 
headaches by the patient. 

(b) Headache is, therefore, one of the most common and significant 
signs of sinuitis, though it may be present when the middle turbinal 
presses against the septum. This condition is often mistaken for eye- 
strain. Refraction is rarely satisfactory, and only when the anterior 
end of the middle turbinate is removed is the headache relieved and 
glasses accepted. In many cases glasses are not necessary. Head- 
ache has multitudinous causes, and is not, therefore, pathognomonic 
of inflammatory or other diseased conditions of the sinuses. Headache 
may signify eyestrain, but in this case it is usually bilateral, whereas in 
sinus disease it is more often unilateral, or, if not unilateral, more pro- 
nounced on one side, or it begins as a unilateral headache and extends 
♦to the other side. The headache which originates in a sinus is increased 
upon stooping forward and upon sudden jarring of the body. It may 
persist upon closing the eyes upon retiring, or in a darkened room; 
whereas if it is of ocular origin it disappears under such conditions. 

The headache of ocular origin is greatly increased upon prolonged 
reading and upon attendance at the theatre. The headache caused by 
attendance at the theatre is so characteristic of ocular disturbance that 
it may be termed "theatre pain." This type of pain is not characteristic 
of sinus disease. 

The pains and headache due to disease of the frontal sinus may 
assume the form of sharp, shooting pains through the eyes, or they 
may be dull and heavy, and nearly constant; or they may consist of a 
dull feeling in the forehead, which is aggravated by leaning forward, 
and which in females is especially well marked during each menstrual 
period (H. M. Fish). Pressure under the floor of the sinus at the inner 
angle of the orbit usually elicits pain in these cases. 

(c) Tenderness upon Pressure. — Tenderness and pain upon finger 
pressure may be present in disease of those sinuses contiguous to the 
surface of the face, viz., the frontal, anterior ethmoidal, and the maxil- 
lary sinuses. 

For the examination of the frontal sinus, pressure should be made 
over the anterior wall above the supra-orbital ridge, and under the floor 
of the sinus near the inner angle of the orbit. 



186 



THE NOSE AND ACCESSORY SINUSES 



Fig. 133 



In the examination of the anterior ethmoidal cells, pressure should 
be made at the inner angle of the orbit against the orbital plate of the 
ethmoid. 

In the examination of the antrum of Highmore, pressure should be 
made over the canine fossa of the superior maxilla. 

(d) Disturbance of Equilibrium. — Giddiness and vertigo or a momen- 
tary sense of blurred or darkened vision and imminent fainting are 
frequently present in disease of the sinuses. All these symptoms may 
be aggravated or produced by stooping forward. The patient should 
be carefully questioned in regard to these symptoms, as otherwise they 
may be overlooked. 

(e) Disturbances of the Special Senses. — The olfactory, visual, and 
auditory senses are frequently disturbed or altogether lost in sinuitis. 

The olfactory sense may be perverted (parosmia), the patient appar- 
ently perceiving odors that are not in evidence to normal noses. A 
more common symptom is the loss of olfaction (anosmia). This is 
accounted for by the blocking of the olfactory fissure by the tissues 
in the region of the middle turbinate. The ventilation of the superior 

meatus of the nose is thereby pre- 
vented, hence the loss of the sense 
of smell. In some cases this may 
be due to the degeneration of the 
terminal filaments of the olfactory 
nerve, although in most cases coming 
under my observation the sense of 
smell is regained after opening the 
olfactory fissure either by removing 
the obstructive tissues or by resort- 
ing to some surgical procedure, as 
the removal of polypi, a portion of 
the middle turbinate, or correcting a 
deviation of the septum. 

The ocular function may be dis- 
turbed or altogether lost in the course 
of sinus disease. The disturbance 
may be due to either arterial or 
venous congestion, and to toxins, or 
to thrombosis of the veins intercom- 
municating between the sinuses and 
the eye. The morbid process in the eye may take the form of a papil- 
litis, neuroretinitis, retrobulbar disease, keratitis, errors of refraction 
or of accommodation, photophobia, epiphora, choroiditis, marginal 
blepharitis, iridocyclitis, conjunctival injection, restricted field or loss 
of vision. 

Relation of the Eye to Disease of the Sinuses. — The intimate rela- 
tion between the veins of the nose and accessory sinuses and of the eye 
(Fig. 133), as demonstrated by Dr. H. M. Fish, Dr. W. C. Posey, and 
others, shows how reasonable is the assumption that many of the ocular 
lesions heretofore attributed to auto-intoxication from the intestines, 




Schema showing the venous connections 
of the ethmoidal cells with the eyeball: 
a, a, a, a, anterior and posterior ethmoidal 
cells; b, eyeball; c, superior ophthalmic 
vein; d, posterior ethmoidal vein; e, ante- 
rior ethmoidal vein. 



GEXERAL CONSIDERATIONS IN REFERENCE TO SINUSES 187 

gonorrhea, syphilis, and rheumatism, may, in many instances, be due 
to an extension of the disease from the sinuses to the ocular apparatus 
via the veins and lymphatics. 

According to Posey, the extra-ocular muscles may become paretic 
or paralyzed from inflammation of the sinuses, because the nerves which 
supply the muscles are in close anatomical relationship with the walls 
of the sinuses and may be paralyzed by pressure or by toxic influences. 
The levator, superior oblique, and superior rectus muscles are in relation- 
ship with the floor of the frontal sinus, and paralysis of them is indicative 
of disease of the frpntal sinus. The internal rectus muscle is in relation- 
ship to the inner orbital or ethmoidal wall and paralysis of this muscle 
is indicative of disease of the ethmoid cells. The inferior oblique and 
the inferior rectus muscles are in relationship to the superior wall of the 
antrum (floor of the orbit) and paralysis of either of these muscles is 
indicative of disease of the antrum. As the nerves which supply all 
these muscles pass in apposition or close approximation to the sphenoid 
sinus, disease of this sinus may involve one or more of the muscles, 
hence, each case must be carefully studied before the location of the 
inflammation can be determined. Paresis of either of these muscles 
causes a type of diplopia or squint. Diplopia may also be due to retro- 
bulbar pressure causing displacement of the eyeball. 

Optic neuritis or other disease of the eye and adnexa is frequently due 
to disease of the nasal accessory sinuses, more particularly the ethmoid 
and sphenoid sinuses. C. R. Holmes reviewed the literature on the 
subject and found several cases on record. In one case the patient 
died of cerebral hemorrhage, and at the autopsy it was found that the 
roof of the sphenoid, including the bone and dura, was destroyed. 

Three cases of optic neuritis with partial and complete blindness 
have come under my observation and operative treatment within the 
past two years. The first case was referred to me by Dr. J. G. Huizinga 
with the diagnosis of optic neuritis due to ethmoidal and sphenoidal 
disease. His diagnosis was confirmed by Drs. C. A. Wood and 
G. F. Suker. The patient was thirty-five years of age and was single; 
syphilis had been excluded. His vision was yf-Q-. The defective vision 
had been present for four months. I performed an ethmoidal exen- 
teration, and removed the anterior wall of the sphenoidal sinuses upon 
both sides. The vision rapidly improved to -f-|, where it has remained 
two years after the operations. 

The second case had been under treatment with electricity, etc., for 
eighteen months and the vision had gradually declined. At the end 
of this time the case was referred to me by Dr. J. E. Colburn for opera- 
tion upon the ethmoidal and sphenoidal sinuses. After the operation 
vision continued to decline. 

The third case was referred to me by Dr. G. F. Suker for operation 
upon the ethmoidal and sphenoidal sinuses. The patient was forty- 
two years old; syphilis was excluded. He was totally blind, not being 
able to see a lighted match. The blindness had been present for two 
weeks. I operated upon the right ethmoidal and sphenoidal sinuses at 



188 THE NOSE AND ACCESSORY SINUSES 

once and the vision began to improve. Ten days later I operated upon 
the left side. The vision receded for two or three days and then began 
to improve rapidly, until at the end of six weeks it was normal. 

The auditory functions may be more or less disturbed by disease of a 
sinus. The discharge from the sinuses into the epipharynx may cause 
infection of the mucous membrane of the Eustachian tube and middle 
ear. Sinuitis may indirectly be the cause of catarrh of the middle ear 
or of suppurative otitis media and mastoiditis. In addition to the fore- 
going aural complications, there is another symptom which I have not 
seen mentioned in the literature, namely, a momentary roaring accom- 
panied by a fulness in the ears and dulness of hearing. These phenomena 
are especially likely to occur on bending forward. 

The Principles of Treatment. — The cure of inflammation of a sinus 
depends upon three things, namely : (a) The establishment of free drainage 
and ventilation, (b) the removal of the morbid material, and (c) the 
elevation of the opsonic index by the administration of autovaccines. 

In those cases in which the interference with drainage and ventilation 
is due to a simple hyperemia of the mucous membrane the local applica- 
tion of cocaine, antipyrine, or adrenalin may be quite sufficient to estab- 
lish a cure. In such subjects the morbid material is the secretion, hence 
drainage removes it. On the other hand, in those cases in which there 
is a marked obstruction due to a deviation of the septum or to hyperplasia 
or cystic enlargement of the middle turbinate, it is often necessary to 
resort to surgical measures in order to give relief. Furthermore, in those 
cases in which the sinus is filled with granulation tissue and the bony 
walls are necrosed the establishment of drainage even by surgical means 
may not effect a cure; the morbid material (granulations and necrotic 
bone) must also be removed. 

The Indications. — An appreciation of these fundamental principles 
enables the surgeon to decide upon the method of treatment in each case. 
In the following discussion of the treatment the foregoing principles will 
be constantly referred to, with a view to enabling the student and prac- 
titioner to elect the proper mode of treatment in the cases coming under 
his observation. Before entering upon a detailed description of the 
various modes of treatment a general discussion of the varying conditions 
to be met will be given. 

Acute catarrhal sinuitis is usually an extension of a similar inflamma- 
tion of the nasal mucosa to the sinus, in the course of a coryza or cold 
in the head. The mucous membrane of the nose and sinuses is hyperemic 
and swollen. The ostia and the infundibulum may be closed from swell- 
ing of the mucous membrane. The obvious indication is to relieve the 
swelling by the local application of certain drugs; surgical intervention 
is rarely necessary. 

Acute suppurative sinuitis occurring in the course of coryza is charac- 
terized by hyperemia and swelling of the mucous membrane of the nose 
and sinuses, and the indications are to reduce the swelling by local medi- 
cinal applications, as in the acute catarrhal variety. 

Chronic catarrhal sinuitis due to pressure in the middle turbinate 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 189 

region necessitates the removal of the tissue which causes the pressure. 
If the mucous membrane is chronically swollen, temporary relief may 
follow the application of antiphlogistic drugs, as adrenalin. If the 
secretions have dried and blocked the cell openings, probing may afford 
temporary relief. In most cases the middle turbinate is enlarged from 
hyperplasia (see Hyperplastic Rhinitis, Polyp), or from bullous enlarge- 
ment which blocks the infundibulum. In some cases, therefore, it is 
necessary either to straighten the septum or remove a portion of the mid- 
dle turbinate in order to give permanent relief. The bulla ethmoidalis 
may also block the infundibulum and prevent drainage and ventilation 
of the sinuses in Series I. 

Chronic suppurative sinuitis, with obstructive lesions, necessitates their 
removal, whether they be of septal, turbinal, or other origin. In this 
case there is simple obstruction, and no morbid material other than pus 
is present; hence the removal of the obstructive lesion permits of drainage 
which removes the pus. The foregoing statement does not apply, how- 
ever, to all cases, as the drainage of pus from the cells is not altogether 
dependent upon free cell openings, because in most of the cells the 
opening is near the upper limit. The ciliated columnar epithelium w T hich 
lines the cells, though limited in distribution, carries the secretions up to 
the cell openings, where it is discharged into the nasal cavity. If, there- 
fore, the cilia? are destroyed by the inflammatory process, the removal 
of the obstructive lesions does not necessarily establish free drainage. 
In such cases it may be necessary to institute operative procedures in 
order to open the cells at their most dependent portion, or to exenterate 
them in their entirety (ethmoidal). In some cases the mucous membrane 
and the ciliated epithelium can be restored to their normal integrity and 
functional activity by lavage, or by negative air pressure, as recommended 
by Bier. 

Chronic sinuitis, without obstructive lesions of the septum or the 
middle turbinated body, implies a hyperplasia of the mucous mem- 
brane with a loss of the columnar ciliated epithelium of the sinuses, 
at least in certain areas. These cases, according to UfTenorde and 
Skelleren, are not attended by suppuration. My personal observations 
do not confirm their view, as I have often opened the frontal sinuses 
and have found both hyperplasia of the mucous membrane (polypi) and 
pus. I have, however, more often found only polypi present. I do not 
understand that hyperplastic tissue is immune to pus producing micro- 
organisms, but, on the contrary, I can conceive on both theoretical and 
clinical grounds that purulent secretions may and do accompany hyper- 
plastic rhinitis and sinuitis. The treatment should therefore either be 
directed to the regeneration of the mucous membrane by negative 
pressure, and the resultant hyperemia and increased nutrition, or by open- 
ing the cells and establishing free drainage by some operative procedure. 

Chronic suppurative sinuitis, with granulations, polypi, or necrosis of 
the bone, is only amenable to surgical treatment. No treatment other 
than this will establish drainage and ventilation and remove the morbid 
material. 



190 THE NOSE AND ACCESSORY SINUSES 

Treatment. — The principles of treatment having been given, only 
the technique will be described in this section. 

Treatment of Acute Catarrhal Sinuitis. — Acute catarrhal sinuitis usually 
involves all the accessory sinuses, and the indications call for the reduc- 
tion of the swelling of the mucous membrane for the purpose of open- 
ing the ostia of the sinuses. The following technique is usually suc- 
cessful : 

(a) Apply adrenalin, 1 to 2000, on thin pledgets of cotton, to the 
swollen middle and inferior turbinates to reduce the swelling. 

(6) Apply a 4 per cent, solution of cocaine to reduce the swelling and 
to relieve the hypersensitiveness of the mucous membrane. 

(c) Apply a 10 per cent, solution of antipyrine over the same area to 
prolong the ischemic effects of the adrenalin and cocaine. 

(d) Use a 0.5 per cent, solution of menthol or other bland aromatic 
oily solution with a nebulizer every two or three hours. 

The solutions of adrenalin, cocaine, and antipyrine should be used as 
often as the nasal chambers feel "stuffy," or the headache and sense 
of pressure return. 

In addition to the foregoing local remedies, those which are usually 
given in acute coryza may be administered, but they are of value only 
in the early stage. (See Treatment of Coryza.) 

Heat from a 500 candle-power lamp applied over the face some- 
times affords speedy relief. The lamp should be passed back and forth 
before the closed eyes, at a distance of from twelve to eighteen inches 
for twenty to thirty minutes. The good effects are due to the increased 
hyperemia and leukocytosis, and to the improvement of the nutri- 
tion. While germicidal properties are claimed for the light of this 
lamp, the effects are probably due to the increased leukocytosis and 
nutrition of the tissues. I have thus treated chronic cases in which the 
purulent discharge and pain ceased, but returned after a few weeks. 
Whether persistent use of the light will cure these cases I am not pre- 
pared to state. 

Treatment of Chronic Catarrhal Sinuitis. — This is a more difficult type to 
treat successfully on account of its chronicity, which of itself may imply 
that anatomical barriers existed during the acute stage which prevented 
resolution. These barriers, if present, must be overcome before a cure 
can be permanently established. The anatomical barriers to resolution 
may consist of hypertrophic or hyperplastic changes in the mucous mem- 
brane of the nose, especially in the region of the cell openings and the 
olfactory fissure, or they may be due to ethmoidal cells in the middle 
turbinate or to deviations of the upper portion of the nasal septum. 

The swelling of the mucosa may be somewhat reduced by the local 
applications of adrenalin, cocaine, and antipyrine. In addition to this 
the hyper trophic or hyperplastic rhinitis should be surgically treated 
after the manner described under these diseases. 

If these measures fail, more radical surgical procedures, such as are 
used in obstinate cases of suppurative sinuitis, may become necessary. 
Probing of the frontonasal canal sometimes affords relief, although the 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 191 

removal of the anterior end of the middle turbinate and the curettement 
of the ethmoidal cells may be necessary. 

Treatment of Chronic Suppurative Sinuitis. — In the simpler form of 
sinuitis, that is, when there are no granulations nor carious bone, the 
lavage of the affected sinus with antiseptic, alkaline, or stimulating solu- 
tions is sometimes followed by a cure. The lavage of the frontal sinus 
may be performed through the frontonasal canal, except in those cases 
in which it is absolutely closed by an enlarged bulla or by an enlarged 
middle turbinated body. 

Fig. 134 




Probing the frontal sinus. The anterior half of the middle turbinated body is removed to show 
the anatomical landmarks: a, a, the probe in the first position beneath the middle turbinate and 
posterior to the bulla ethmoidalis ; b, the probe in the second position beneath the middle tur- 
binate and in front of the bulla ethmoidalis; c, c, the probe in the third position introduced through 
the frontonasal canal into the frontal sinus; d, the nasal end of the frontonasal canal; e, the lip of 
the uncinate process; /, the inner wall (uncinate process) of the infundibulum; g, the ostium bulla 
ethmoidalis; h, the ostium maxillare; i, an accessory opening into the maxillary sinus. (Drawing 
from a specimen loaned by Dr. Ira Frank.) 



Lavage of the Frontal Sinus. — An understanding of certain anatomical 
peculiarities of the region of the infundibulum and the frontonasal 
canal will materially aid in the lavage of the sinuses. The hiatus semi- 
lunaris, the infundibulum, and the frontonasal canal will be clearly 
defined, as much confusion appears in the literature concerning them. 
The terms are often used as synonymous, whereas they are distinct 
anatomical entities. 

The hiatus semilunaris is a slit-like crescentic-shaped opening in the 
outer wall of the nose. It is the opening of the infundibulum into the 
middle meatus. Its inner lip is the upper margin of the uncinate process 
of the ethmoid bone. 

The infundibulum is a deep, narrow groove or gutter in the outer wall 
of the nose (Fig. 134,/), the inner wall of which is the uncinate process. 
The frontonasal canal drains into the infundibulum in about one-half 



192 THE XOSE AND ACCESSORY SINUSES 

of the subjects, whereas in the remainder it drains a little anterior to 
it directly into the middle meatus (Turner). 

The frontonasal canal is a closed tubular duct extending upward and 
forward from the middle meatus or the infundibulum, as the case may be, 
to the frontal sinus. Its opening into the floor of the frontal sinus is 
known as the ostium frontale. In rare instances the ostium opens high 
upon the posterior wall of the sinus. 

Having defined the parts concerned in probing or irrigating the frontal 
sinus, certain anatomical peculiarities which influence the procedure 
will be given brief notice. 

The hiatus semilunaris is the key to the probing, as it is the opening 
into the infundibulum, which must be entered to reach the frontonasal 
canal in about one-half of the cases. The bulla ethmoidalis is situated 
just above the hiatus, and when large it encroaches upon the slit-like 
opening and partially or completely closes it. Occasionally there are 
accessory cells in the uncinate process, which also obstruct the hiatus. 
In other cases the middle turbinate closely hugs the outer wall of the 
nose and blocks the hiatus (Sluder). When either of these anatomical 
peculiarities is present the introduction of the probe or the cannula is 
rendered difficult or impossible. If the frontonasal canal opens in front 
of the infundibulum the probe or cannula may be passed into it even 
though the hiatus is closed. 

Fig. 135 



X. 



Holmes' malleable frontal sinus probe. 

Another difficulty sometimes encountered in probing is, that the probe 
may enter the ostium of one of the anterior ethmoidal cells instead of 
the frontal sinus. Some of the anterior cells may open into the infun- 
dibulum on its outer wall, while others open into the frontonasal canal. 
The anterior cells are usually located external to the infundibulum and 
the frontonasal canal, and their ostia open into the infundibulum and 
frontonasal canal, through the outer wall. In probing, therefore, the 
point of the probe should be kept against the inner or mesial wall of 
the frontonasal canal in order to avoid the ostia on its outer wall. 

Probing is generally more difficult in those subjects in which the 
frontonasal canal empties into the infundibulum than when it empties 
directly into the middle meatus. In the former case the canal is often 
tortuous and narrow, while in the latter it is usually straighter and of 
larger caliber. 

The middle turbinate is sometimes so close to the hiatus, especially 
when the turbinate contains an accessory cell, that it is difficult to enter 
it with a probe or cannula. In this event the removal of the anterior 
third of the middle turbinate overcomes the difficulty. 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 193 

Technique of Probing the Frontonasal Canal. — First cocainize the 
parts. Then introduce a fine silver probe (Fig. 135), bent at its 
distal end to an angle of about 135 degrees, between the anterior third 
of the middle turbinate and the outer wall of the nose. Keep the tip of 
the probe against the outer surface of the turbinate and pass it forward 
and upward through the hiatus into the infundibulum, where it readily 
enters the frontonasal canal even to the ostium frontale (Fig. 134). 
After engaging in the middle meatus it should be passed into the infun- 
dibulum and canal for about 6 to 8 cm. to reach the frontal sinus. 

Irrigation of the frontal sinus is accomplished through a silver 
cannula, which is introduced in the same manner as described for the 
introduction of the probe. The syringe is attached to the cannula, 
and the sinus gently irrigated with warm normal salt or boric acid 
solution. 

Lavage of the Maxillary Sinus. — This can rarely be effected through 
the cell opening on account of its hidden position in the infundibulum, 
and on account of its forward and downward direction from the infun- 
dibulum to the antrum. The opening into the antrum is not directly 
through the lateral wall of the nose, but it is more like a canal extend- 
ing obliquely downward and forward through the thickness of the 
wall. The canal or opening is furthermore somewhat hidden by the 
unciform process, or lip, of the hiatus semilunaris. Some writers have 
claimed that they could irrigate the antrum through its normal open- 
ing, but a casual study of the anatomical peculiarities of the region 
will convince anyone that it is a physical impossibility, except in rare 
instances. In a certain number of cases there are accessory openings 
into the antrum (Fig. 134, i), which when present may be utilized 
for purposes of irrigation. Then, too, the lamina membranacea of the 
naso-antral wall may be perforated with the tip of the cannula and irriga- 
tion performed through it. In view of the foregoing facts it is rarely 
possible to irrigate the antrum through the normal ostium, hence an 
artificial route should be chosen, the most available one being beneath 
the inferior turbinated body, a curved trocar and cannula being used 
for the purpose. The technique is as follows: 

(a) Anesthetize the mucous membrane of the inferior meatus with 
a 5 per cent, solution of cocaine. 

(b) Introduce the trocar and cannula beneath the inferior turbinate 
posterior to the anterior antral wall, and direct it upward and outward, 
i little above the floor of the nose, in order to avoid the thick wall of 
bone at this point. In some cases, especially when a maxillary cyst is 
present, the floor of the antrum is quite high and it is not possible to 
introduce the trocar beneath the inferior turbinate. 

(c) After penetrating the naso-antral wall, remove the trocar, leaving 
the cannula in position. 

(d) Attach the rubber hose of the syringe to the cannula and irrigate 
with normal salt or other solution chosen for the purpose. 

(e) By cocainizing the area daily, the irrigations may be continued 
indefinitely through the artificial opening. 

13 



194 THE NOSE AND ACCESSORY SINUSES 

Lavage of the Antrum through the Alveolar Process. — This may be 
done after having performed the Cooper operation, so named after Sir 
Astley Cooper, who introduced it to the profession. 

The technique is as follows: 

(a) Select a place where a tooth has been extracted below the antrum, 
or if a tooth is decayed beyond repair, extract it for the purpose, and 
drill a canal into the floor of the sinus. This is Cooper's operation. 

(6) Through this opening a cannula is introduced and the antrum 
irrigated with normal salt or any solution desired. 

(c) The canal thus made should be kept open by means of a hard 
or soft rubber or gold tube made for the purpose. The tube should 
be flanged on the lower end to prevent it slipping upward into the 
antrum. 

(d) A plug should be introduced into the tube to prevent the entrance 
of food into the antrum. This method is obsolete. 

Lavage through a Canal External to the Teeth. 

(a) Cocainize the gums. 

(b) Drill a canal through the upper and external part of the alveolar 
process at a point between the first and second biscuspids, avoiding the 
roots of the teeth. This method is practically obsolete. 

(c) Proceed thereafter as in the Cooper operation. 

Lavage of the Ethmoidal Cells. — This is often impossible except in 
the case of the anterior cells which drain into the frontonasal canal. 
The bulla ethmoidalis, one of the anterior cells, does not drain into 
the frontonasal canal, but drains directly into the middle meatus, and 
its ostium is situated at its upper median wall beneath the attachment 
of the middle turbinated body. 

The technique for the lavage of the anterior cells opening into the 
frontonasal canal is the same as for the frontal sinus, this being intro- 
duced into the canal only to the second position (Fig. 134); indeed, 
both sets of cells are often irrigated at the same time. Their ostia are 
bathed with the irrigating fluid and the accumulated pus in the canal 
is removed, thus facilitating the drainage of the cells. 

Lavage of the sphenoidal sinus is possible when the middle turbinate, 
or a deflection of the septum, does not prevent the introduction of the 
sphenoidal cannula into its opening. When such an obstruction is present 
it may become necessary to first remove it by some surgical procedure 
before the irrigations can be practised. I generally use a silver Eustachian 
catheter in place of a sphenoidal cannula, and find the curve used for 
the inflation of the ear the correct one for irrigation of the sphenoidal 
sinus. Myle's cannula may be bent to reach any sinus, and is smaller 
than the Eustachian catheter. A. H. Andrews has devised a curved 
cannula (Fig. 136) which can be introduced into the sphenoidal sinus 
without the preliminary removal of the middle turbinated body. This 
is a decided advantage, as it renders the treatment of empyema of this 
sinus a very simple procedure. Should granulations be abundant, it 
may be necessary first to remove the middle turbinate and then the 
anterior wall of the sphenoidal sinus, and curette its interior. 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 195 

The special curve of Andrews' cannula enables the operator to insin- 
uate it through the olfactory fissure into the spheno-ethmoid fossa, and 
to engage the tip in the ostium sphenoidale by rotating it (Fig. 137). 
When it has been introduced, the patient should be instructed to lean 

Fig. 136 



*CQ 



|6". |7'. 18 '19 • I. 



Andrews' sphenoidal probe cannula and knives. 



forward and open his mouth; then the hose of the syringe ^ should be 
attached to the cannula and the sinus irrigated. If the patient's head 
is inclined forward and the mouth open the fluid will not enter the 
Eustachian tube. 



Fig. 137 




Irrigation of the sphenoidal sinus with Andrews' curved cannula. 

General Remarks Concerning Lavage or Irrigation of the Sinuses — 
Lavage of the sinuses in suppurative inflammation is, upon the whole, 
an unsatisfactory therapeutic measure. Formerly it was in vogue with 
dentists and surgeons for the treatment of antral empyema, Many 
cases were thus treated daily, for weeks and months, and some were 
cured, or apparently cured, while others continued to suppurate uninter- 
ruptedly. 



196 THE NOSE AND ACCESSORY SINUSES 

If lavage is useful at all it is in the simple suppurative cases uncom- 
plicated by granulations and necrosis. The removal of the purulent 
secretions gives the ciliated epithelium a chance to regenerate. It should 
also be borne in mind that the mucous membrane does not tolerate 
lavage indefinitely, as it is not accustomed to the presence of large 
quantities of aqueous solution, hence irrigation is a doubtful procedure. 
If after a few days' or weeks' trial the case does not greatly improve, 
irrigation should be discontinued and some other method of treatment, 
probably surgical in character, instituted. 

Treatment by Negative Air Pressure. — Bier has demonstrated the 
therapeutic value of this method of treatment in inflammations. Sonder- 
mann, Brawley and others have also reported favorably upon the use 
of negative pressure by means of an exhaust pump. The rationale of 
this meathod of treatment consists chiefly in the increased hyperemia of 
the mucous membrane lining the cells. The local nutrition is thereby 
improved, the cell resistance and leukocytosis increased, and the infective 
process checked. That such changes do take place in some cases thus 
treated is probably true. It is not claimed that all cases are amenable 
to this treatment. Let it be understood, therefore, that negative air 
pressure should be used only as a tentative measure, and if a cure does 
not follow within a few weeks, it should be abandoned and some other 
treatment substituted for it. 

Technique. — (a) The apparatus necessary for producing negative 
pressure in the sinuses consists of either a hand pump or other device 
for exhausting the air in the nasal chambers. Brawley's apparatus is 
operated by attaching it to a faucet of the washbasin, the negative 
pressure being regulated by the amount of water turned on. 

(b) Insert the nasal tips into the nostrils and bring the soft palate 
into apposition with the pharyngeal wall by swallowing. With practice 
the patient soon learns to maintain this condition for several minutes. 

(c) While the air is thus exhausted the pus is drawn from the sinus 
into the rubber tubing, from whence it flows into the reservoir bottle. 
In this way several drams or ounces of pus may be removed in the course 
of a half-hour. 

(d) Daily seances should be maintained until improvement begins, 
or until the surgeon is convinced that this method of treatment is inade- 
quate for the case. 

Drs. Dabney and Pynchon have each devised an exhaust apparatus, 
having the appearance of a spray tube, which is operated with a com- 
pressed-air tank. These are ingenious and practical instruments. 

With either apparatus the patient is instructed to swallow, thus closing 
off the pharynx from the epipharynx and nose. The suction, after 
a little practice on the part of the patient, maintains the palate muscles 
in this position for an indefinite period of time. The patient during this 
process breathes through the mouth. 

Vaccine Therapy. — Vaccine therapy in suppuration of the accessory 
sinuses of the nose, throat, ear, and meninges promises much for the 
future, but unfortunately it is at present far from universally successful. 



GEXERAL CONSIDER AT IOXS IX REFERENCE TO SINUSES 197 

In a recent exhaustive review of the literature on this subject by Dr. Reik, 
both views and results were at great variance. Some writers reported 
excellent results in one or a series of cases, while others reported nega- 
tive or occasional apparent success. Some used autogenous vaccines, 
others stock vaccines. The autogenous vaccines appeared to give better 
results. Some reported good results without operation, others, only after 
operation. Some found better results in acute cases, others in chronic 
cases. One writer, Dr. Nagel, insisted that success depended upon the 
manner in which the vaccine was prepared, i. e., the least amouni of heat 
that will kill the bacteria should be used in preparing the vaccine. She 
reported forty suppurative ear cases treated with autogenous vaccine 
prepared in this way with thirty-nine cures. All the cases have been under 
observation one or two years. She did not, however, particularize the 
cases by giving the full clinical histories. It may be assumed, however, 
that they were of several types, as they were selected at random from Dr. 
C. M. Cobb's clinic at Harvard Medical College. Dr. Cobb corroborated 
Dr. Xagel in every particular, as the work was done under his observa- 
tion and direction. A report of this character from highly credited 
authority leads one to hope much good may be gained by vaccine therapy. 
It also suggests that the great discrepancy in the results obtained by other 
observers may have been due to the faulty method employed (too great 
heat, etc.) in the preparation of the vaccine. In the meantime we 
should continue to use vaccine therapy and insist that the vaccine be 
prepared with the least degree of heat that will kill the bacteria. This 
and other improvements in the preparation, and administration of the 
vaccine, together with the selection of suitable cases, may bring this 
method of treatment to the degree of efficiency it seems upon theoretical 
grounds to deserve. 

Dr. J. F. McKernon believes that in vaccine therapy we have an aid, 
first, in wound repair after mastoid operations following scarlet fever 
and measles; second, in hastening resolution of the accompanying puru- 
lent otitis media; and third, in increasing the patient's resistance to the 
disease by neutralizing the poison in the system, and allowing a more 
rapid tissue repair. In other words, he believes that healing is has- 
tened and depression and scarring are diminished by autogenous vaccines 
in mastoid cases following scarlet fever and measles. 

Technique. — The preparation of the vaccine is a laboratory process 
requiring about forty-eight hours for its completion and will not be 
described. The practitioner should remove some of the purulent secre- 
tion from the nose, throat, ear, or other part involved with a cotton- 
wound applicator, great care being observed to secure it from or as near 
the original point of infection as possible, and to avoid contact of the 
swab with other regions which may contain extraneous micrococci which 
have nothing to do with the infection. The swab thus secured may 
be sealed in a test-tube or smeared at once on a suitable culture media and 
delivered to a competent laboratory expert who will prepare a vaccine 
from it. The laboratory worker should indicate the strength or dosage 
of the vaccine, which should be injected every three days into the 



198 THE NOSE AND ACCESSORY SINUSES 

muscular tissue of the arm, thigh, back, or chest at the discretion of 
the attending physician. 

I have personally used autogenous vaccines in a few cases of extra- 
dural abscess of otitic origin with apparent benefit, though in one 
case without effecting a complete cure. In this case a radical mastoid 
operation was first performed to relieve the meningeal abscess (following 
diphtheria). The acute manifestations rapidly subsided, but a purulent 
secretion, small in amount, continues, after the lapse of five months, to 
discharge from the opening made in the tegmen antri. 



CHAPTER XI 

THE SURGERY OF THE ACCESSORY SINUSES 

THE "KEY" TO DISEASES OF THE SINUSES, OR THE "VICIOUS 
CIRCLE " OF THE NOSE 

In the chapter on the Etiology of the Inflammatory Diseases of the 
Nose and Accessory Sinuses it was shown that the chief predisposing 
cause of inflammation of the sinuses is an obstruction in the region of the 
middle turbinated body and the hiatus semilunaris. The obstructive 
lesion may be a deflection of the nasal septum, an enlarged or cystic 
middle turbinate, an enlarged bulla ethmoidalis, or cells in the uncinate 
process, the median wall of the infundibulum (Figs. 138 to 144). As 
the frontal, anterior ethmoidal, and the maxillary sinuses drain into the 
infundibulum (exceptions noted, p. 164), an obstruction in this region 
mav occlude either or all of these sinuses. When either of them is the 
seat of inflammation it is always advisable to make a careful examination 
of this region. The area to be thus examined is shown in Fig. 145 within 
the circle. These structures may be designated the "key" to inflamma- 
tion of the sinuses, or the "vicious circle" of the nose. Being the key to 
the etiology of infection, it is also the key to the treatment of the infection; 
that is, if the obstruction predisposing the sinuses to infection is located 
within the area of the circle, it is obvious that if this area is freed from> 
obstruction the chief etiological factor will have been removed, and 
having been removed the infectious process tends to subside. 

The following principle may, therefore, be given as a working basis 
in the treatment of inflammatory diseases of the sinuses composing 
Series I. (See Chapter 'IX.) 

Remove the obstruction within the "key," or "vicious circle" before 
attempting more radical measures. 

By so doing the drainage of the sinuses may be established and a cure 
result. This principle is of so nearly universal application that it forms 
a good working basis, and, if observed, will prove of inestimable value, 
as it will often obviate the necessity of resorting to the more radical 
operations in the treatment of the sinuses. Should the recommendations 
given above fail to relieve the disease, the more radical operative pro- 
cedures may be performed in due time. 

Various writers have made clinical observations that meningitis is 
more likely to follow the radical external operation if an intranasal 
operation is performed a few days prior to the radical operation. The 
following deduction is, therefore, obvious: 

Never "perform a preliminary intranasal operation a feiv days before a 
radical operation on a sinus. 

(199) 



Fig. 138 



Fig. 139 





A high deviation of the septum, causing 
closure of the infundibulum: a, high deviation 
of the septum; b, inner wall of the bulla eth- 
moidalis; c, middle turbinate crowded against 
the outer wall of the nose and blocking the 
drainage of the infundibulum. 



Cross-section through the nose: a, hyper- 
plasia of the middle turbinated body, which 
crowds upon the uncinate process (c) and closes 
the infundibulum. 



Fig. 140 



Fig. 141 





Edema of the mucous membrane of the 
middle turbinate, blocking the infundibulum : 
a, edematous middle turbinate; b, bulla eth- 
moidalis; c, uncinate process or inner wall of 
the infundibulum 

(200) 



A large cell in the middle turbinated body, 
occluding the infundibulum: a, cell in middle 
turbinate; b, the inner wall of the bulla eth- 

moidalis; c, the uncinate process or inner wall 

of the infundibulum or gutter. 



Fig. 142 



Fig. 143 





Cell in the uncinate process (b) blocking the The middle turbinated body (a) clinging to 

infundibulum; a, bulla ethmoidals ; c, middle the outer wall of the nose and blocking the 
turbinated body. infundibulum; 6, inner wall of the bulla eth- 

moidalis; c, uncinate process or inner wall of 
the infundibulum. 



Fig. 144 




Enlargement of the bulla ethmoidalis, blocking the infundibulum: a, the inner and distended 
wall of the bulla ethmoidalis, crowding inward and downward against the uncinate process and 
blocking the infundibulum; b, the uncinate process; c, the middle turbinate, which, on account 
of the bulging bulla, appears to be the cause of the blockage, whereas the bulla blocks. 

(201) 



202 



THE NOSE AND ACCESSORY SINUSES 



Several days or a few weeks should elapse between them, to allow a 
wall of protecting granulation tissue to be formed. An additional reason 
for delaying the radical operation is, to allow sufficient time to elapse to 
determine whether the intranasal operation is adequate to cure the dis- 
ease. I have seen serious cases cured most unexpectedly under such 
treatment. I wish to state most emphatically, however, that, having 
found the simple intranasal operation ineffective, the surgeon should 
unhesitatingly perform a more radical operation. My plea is for rational- 
ism rather than against radicalism. I do not plead for so-called "con- 

Fig. 145 




The "vicious circle" of the nose: b, the spheno-ethmoidal fossa; c, the superior turbinated body: 
d, posterior ethmoidal cells; e, bulla ethmoidalis; f, anterior ethmoidal cells draining into the 
frontonasal canal; g, frontal sinus; h, the ostium of the bulla ethmoidalis; ?', hiatus semilunaris; 
k, the uncinate process or outer wall of the infundibulum or gutter on the outer wall of the nose 
into which the frontal, anterior ethmoidal, and maxillary sinuses usually drain. The high light 
below and anterior to j and k indicates the inferior boundary of the infundibulum or gutter into 
which the sinuses drain. The middle turbinated body is removed to exhibit the anatomical details 
beneath it. 

servatism," a term which has been used to justify timidity and surgical 
inefficiency. The true conservative is a rationalist who dares to refrain 
from radical procedures, and yet who dares to undertake them when 
indicated. 



SURGERY OF THE FRONTAL SINUS 

How to Choose a Sinus Operation. — In a study of the operative 
indications, the sinuses naturally fall into three groups, namely: (1) The 
maxillary, (2) the posterior ethmoidal and sphenoidal, and (3) the 
frontal and anterior ethmoidal sinuses. This subdivision is due to 
the anatomical arrangement of the drainage system of the sinuses, 
and the relation of some of the teeth to the floor of the antrum. 



THE SURGERY OF THE FRONTAL SINUS 203 

The drainage and ventilation of the antrum are effected through the 
osteum maxillare, which opens into the bottom of the infundibulum, a 
gutter-like depression in the outer wall of the nose, beneath the middle 
turbinated body. In about half of the cases the sinus has additional 
openings above and posterior to the infundibulum in the membranous 
portion of the nasomaxillary wall. It. would be of interest to know 
whether the accessory openings influence the frequency or character of (he 
infection of this sinus. Theoretically the accessory ostea should reduce 
the frequency and severity of the infection and inflammation on account 
of the better drainage and ventilation they afford. If, for example, the 
osteum maxillare is obstructed, the accessory ostea' would still afford 
ample drainage and ventilation and thus reduce or prevent infection 
and inflammation. If, however, there are no accessory ostea and the 
osteum is obstructed, the conditions are more favorable for infection and 
inflammation. We propose, therefore, to base our study upon the broad 
principle of adequate drainage and ventilation, and certain other con- 
ditions which we believe are of secondary importance. 

1. The Maxillary Sinus. — When the maxillary sinus is the site of 
infection and purulent inflammation, how shall we determine what type 
of operation is required to establish free drainage and ventilation ? 

Several factors enter into the equation. Of these the first is, Was the 
infection of intranasal or of dental origin ? If of dental origin, the proper 
treatment of the carious tooth, combined with simple puncture through 
the nasomaxillary wall, may be all that is required to effect a cure. The 
acuteness and chronicity of the disease also influence the method of 
treatment. If the attack is acute and primary, astringent remedies, 
cocaine, adrenalin, and antipyrine, locally applied, or simple puncture and 
lavage may be effective. If the attack is an acute exacerbation upon 
an old chronic inflammation these remedial measures would in a large 
number of cases only relieve and not cure the disease. 

If the exacerbation is severe and one of several such manifestations, 
the nasomaxillary wall should be extensively resected. The partial 
removal of this wall is usually attended by a continuation of the disease, 
as the opening rapidly closes by granulations from its margins. 

If the conditions described in the preceding paragraphs are present 
and polypi are found in the maxillary cavity, the complete removal 
of the nasomaxillary wall except by the Canfield-Ballenger operation, 
may not establish a cure, as the polypi and diseased mucous membrane 
are not accessible through the nose, and simple drainage and ventilation 
are not always followed by the regeneration of the diseased mucous 
membrane. In such cases the Caldwell-Luc, the Denker, or the Can- 
field-Ballenger operation is indicated. The latter operation is the best 
and simplest. 

2. Posterior Ethmoid and Sphenoid. — When confronted with posterior 
ethmoidal and sphenoidal disease there is no choice as between an intra- 
nasal and extranasal operation, as these cavities can only be reached 
through the nasal chambers, unless, indeed, they are approached via 
the inner angle of the orbit, a route much less desirable than the intra- 



204 THE NOSE AND ACCESSORY SINUSES 

nasal one, except when the anterior ethmoidal cells are also extensively 
diseased, in which case it may be necessary to operate via the external 
route. 

If the case is catarrhal, or only discharges pus during an attack of acute 
coryza, the removal of the middle turbinal may be all that is necessary. 
Such cases are usually characterized by headache, more pronounced in 
its beginning on one side, often present upon awaking in the morning, 
and dizziness upon stooping. Objectively the nasal cavities may be free 
of purulent secretion, except when the patient is suffering from acute 
coryza, at which time purulent secretion is present. The middle turbinal 
is usually bullous and lies against the septum. Such cases are often cured 
by the removal of the middle turbinal. If in addition to the above 
symptoms there is a chronic purulent secretion discharging through the 
olfactory fissure, and through the choana into the epipharynx, and if 
polypi are found in the olfactory fissure the middle turbinal and posterior 
ethmoidal cells should be completely exenterated. The anterior and a 
portion of the inferior walls of the sphenoidal cavity should also be freely 
removed. The complete exenteration of the posterior ethmoidal cells is 
not always easy, or even possible to do, in some cases, as the anatomical 
arrangements of the cells in relation to the sphenoid and the other 
structures of the head renders them inaccessible except by jeopardizing 
vital structures. Dr. Wales has a bony specimen in which the cells pass 
around the side of the sphenoid sinus to its posterior aspect, and seem 
to communicate with the mastoid cells. In such a case it is obviously 
impossible to completely exenterate the ethmoidal cells. I have a case 
under my care in which the posterior ethmoidal cells extend backward 
along the side of the sphenoid sinus on the right side, and in so far as I 
am able to demonstrate they may extend behind it. I have been unable 
in this case to completely check the ethmoidal discharge; vaccine treat- 
ment might be of great value here. 

If the sphenoidal involvement is acute or subacute, the removal of the 
middle turbinated body will usually establish adequate drainage and 
ventilation. If it is chronic and the mucous membrane is edematous or 
has undergone hyperplastic changes (polypi), it will be necessary to first 
remove the middle tubinated body and then completely remove the 
anterior wall of the sphenoidal cavity, especially at its lower portion, where 
the wall may be from one-eighth to one-quarter of an inch in thickness. 
A Hajek or Fletcher punch forceps should be used for this purpose, 
as they are powerful enough to cut the heavy bone. 

The Frontal and Anterior Ethmoidal Cells. — As the frontal and anterior 
ethmoidal cells are nearly always simultaneously involved, it is necessary 
to consider the surgical indications together; indeed, this fact throws a 
suggestive side light upon the choice of an operation. It is obvious that 
if both systems of cells are simultaneously involved, an operation must be 
chosen that will adequately drain both. If the disease is primary and 
acute, the application of ischemic remedies, as cocaine and adrenalin, to 
the upper and anterior portions of the nasal chambers may establish 
good drainage and ventilation. If this fails, the removal of the anterior 



THE SURGERY OF TEE FRONTAL SINUS 205 

half of the middle turbinal may clear the region of the infundibulum 
(vicious circle) of the obstruction, and thus establish free drainage and 
ventilation. If, after removing the middle turbinal, polypi are found in 
the region of the hiatus semilunaris, they should be removed. 

If the polypi rise from the interior of the anterior ethmoidal cells, it 
will be necessary to partially exenterate them via the nasal route. If 
the bulla ethmoidalis is enlarged and overhangs the hiatus, it should 
be removed to establish drainage and ventilation of the infundibulum. 
Indeed, any obstruction in the "vicious circle of the nose," such as 
a high deviation of the septum crowding the middle turbinated body 
against the hiatus semilunaris, a bullous or hyperplastic middle turbi- 
nal, an enlarged or overhanging bulla ethmoidalis or cells in the 
uncinate process which obstruct the infundibulum, should be removed. 

If the case is mild and chronic the procedures above enumerated may 
effect a cure, though in many instances they will fail. If they fail the case 
may still be treated through the intranasal route, by enlarging the fronto- 
nasal duct and removing the floor of the frontal sinus. The choice of oper- 
ation under these conditions lies between the Ingals, the Halle, and the 
Good operations. The Ingals operation enlarges the frontonasal duct with 
a pilot burr, the Good operation with a rasp, while the Halle operation 
removes the floor of the frontal sinus with a series of specially devised 
burrs. The Ingals operation does not establish as large an opening as 
the Good and the Halle operations. It also necessitates the use of a 
drainage tube for several weeks or months. 

If the case is chronic and is attended by acute exacerbations with 
frontal tenderness, an external operation should usually be performed, 
as hyperplastic changes (polypi) are usually present and cause obstruc- 
tion. Of the external operations I can only recommend the Killian, as 
it also includes the exenteration of the anterior ethmoidal cells. Of the 
thirty-five Killian operations performed by me the external deformity 
has been an almost negligible quantity except in one case in which the 
frontal sinuses were large and deep. 

Special Indications. — There are certain special indications for opera- 
tions upon the sinuses which have not been given in the preceding 
portions of this section. They are (a) ocular symptoms, (b) skiagraphic 
findings, (c) intracranial complications, and (d) hay fever. 

(a) Ocular Symptoms. — It is now generally admitted that certain eye 
symptoms are caused by sinus infection, whether the end results of the 
infection are catarrhal inflammation, hyperplasia (polypi), or suppura- 
tion. It is beyond the province of this section to enter into a general 
discussion of eye symptoms in relation to sinus disease, hence I will 
limit my remarks to a few ocular indications for the surgery of the 
sinuses. 

Asthenopia or imbalance of the muscles of accommodation is fre- 
quently due to irritation within the ethmoidal cells. I have repeatedly 
proved this by the proper attention to the ethmoidal labyrinth, a pro- 
cedure which has been followed by the complete relief of the asthenopia. 
Whereas, before the treatment of the ethmoidal disease the patient could 



206 THE NOSE AND ACCESSORY SINUSES 

not be properly fitted with reading glasses, after it he could be perfectly 
fitted, or, as I have found in a number of cases, glasses were not needed. 

In these cases it is often only necessary to fracture the anterior portion 
of the middle turbinal and force it toward the septum, or remove a por- 
tion or all of the middle turbinated body. In others it may be necessary 
to exenterate some or all of the cells. 

Partial or complete blindness may be due to infection of the sinuses, 
the blindness in all probability being due to the absorption of toxic 
material from the affected sinuses. I have seen and operated upon three 
cases of toxic amblyopia of sinus origin. In one case of complete blind- 
ness of recent origin I did a double exenteration of the ethmoidal and 
sphenoidal sinuses, which was followed by the return of vision to normal. 
In the second case the result was not as good, as the blindness had been 
present for four months before the exenteration. In the third case no 
improvement followed the operation, progressive blindness having been 
present for nearly two years before operation. 

These cases are referred to here for the purpose of emphasizing sudden 
or rapidly developing blindness as a possible indication for the surgical 
treatment of the sinuses. Pressure paralysis of the optic and motor 
nerves of the eye may also constitute indications for operation upon 
the ethmoidal and sphenoidal sinuses. 

(b) Skiagraphic Indications. — Skiagraphs of the sinuses show the 
presence of disease, but not the exact pathological condition present. 
For example, given four cases, the first with catarrhal inflammation, the 
second with simple suppurative inflammation, the third with polypi and 
suppuration, and the fourth with the frontal sinus denuded of its mucous 
membrane, the skiagraphic plates will each be cloudy over the frontal 
sinus, but will not indicate the pathological differences. The plates 
will, however, show anatomical points which will aid in choosing an 
operative procedure. 

First, the size and depth of the frontal sinus is shown. If deep and 
large the operator should hesitate to do a Killian operation on account 
of the great deformity which would probably result; he should choose 
the Killian plus the osteoplastic bone flap shown in Beck's operation. If 
the sinus is not deep and large, and all other symptoms indicate an 
external operation, the Killian operation should be elected. 

Second, the plate will show the presence or absence of septa in the 
frontal sinuses (Coakley). If absent, and the case is simple, an intranasal 
operation may be performed with a reasonable assurance of success. If 
septa are present and almost completely divide the sinus, an intranasal 
operation will probably fail. 

Third, the skiagraphic plate will show whether or not the ethmoid 
cells extend over the orbital roof. If they do, an intranasal operation 
upon the ethmoidal labyrinth will probably fail to effect a cure. Such a 
case will probably require a Killian operation if the frontal is also involved, 
and a Moure operation if the ethmoidal alone is involved. 

(c) Intracranial Complications. — The significance of brain abscesses 
and meningitis complicating infection of the nasal accessory sinuses is 



THE AUTHOR'S OPERATIONS WITHIN THE ''VICIOUS CIRCLE" 207 

sometimes an important one. When brain abscess complicates the sinus 
disease the affected sinus or sinuses should be radically operated and 
the abscess drained. When a circumscribed extradural abscess (menin- 
gitis) complicates the disease, the sinuses should not be operated with- 
out due precautionary measures. To operate under such conditions 
would in all probability excite an acute exacerbation of meningitis, 
cause it to become diffuse, and hasten a fatal issue, as occurred in one 
of my cases. 

(d) Hay Fever. — Whether hay fever is ever due to sinus disease is, I 
presume, still an open question. The late Dr. Schadle called attention 
to the apparent relationship of antrum disease to hay fever, and cited 
some cases which were greatly benefited by lavage of the affected antra. 
Pynchon has since then also made similar observations . Personally, I have 
not observed such a relationship. I have, however, seen hay fever sub- 
jects who were afflicted with ethmoidal and frontal disease. In one case I 
did a complete exenteration of both ethmoidal labyrinths, and afterward 
did a double Killian operation upon the frontal sinuses. The patient 
after four years is completely relieved of the hay fever symptoms. 
Previous to the operation the patient was compelled to- sleep in a sitting 
posture for three months each summer and autumn. This, and other 
cases of a similar nature, have led me to infer that sinus disease, especially 
anterior ethmoidal and frontal, may be a more frequent cause of hay fever 
than heretofore suspected. I suspect that catarrhal frontal and ethmoidal 
sinuitis is a more frequent cause of hay fever than the suppurative type. 
The constant discharge of acrid mucus over the area of distribution of 
the anterior ethmoidal nerve might well render this area hypersensitive 
to the pollen or other irritating substances which are the active causes of 
hay fever. I do not claim, nor do I believe, that sinus disease is a con- 
stant factor in the etiology of hay fever. I only suggest that it is some- 
times a cause. If this is true, hay fever may be an indication for the 
surgical treatment of the sinuses, more especially the frontal and anterior 
ethmoidal. 

Surgical treatment of frontal sinuitis may be divided into (a) intra- 
nasal, and (b) extranasal operations. 

The intranasal operations consist in the removal of obstructions within 
the "key," or "vicious circle/ 5 and in the more extensive operations of 
Halle, Good, and Ingals. 



THE AUTHOR'S OPERATIONS WITHIN THE ''VICIOUS CIRCLE" 

Intranasal Operations for Frontal, Anterior, Ethmoidal, and 
Maxillary Sinuitis. — (a) Local cocaine anesthesia should generally be 
depended upon, though general anesthesia is preferable in certain cases. 

(b) Remove the middle turbinated body or such part of it as obstructs 
the area within the circle shown in Fig. 145. Even though the middle 
turbinate does not actually obstruct tho hiatus and infundibulum, it may 
be necessary to remove a portion of it to expose the field to surgical 



208 



THE NOSE AND ACCESSORY SINUSES 



intervention. Physiologically there is little objection to the removal of 
this structure. The olfactory nerve is not distributed to its mucous 
membrane, and the "swell bodies" are rudimentary. The method of its 
removal should be selected with reference to the anatomical conforma- 
tion and the individual preference of the surgeon. The author's turbinal 
knife is usually well adapted to the purpose. 

(c) Remove all of the anterior ethmoidal cells that can be reached 
with the curette, Grunwald forceps, or other instruments. Owing to 
the wide variation in the distribution of the anterior ethmoidal cells, 
the area of curettement varies in each case. In some subjects all the 
cells are not accessible to the curette. Occasionally one of the cells 
extends over the orbital roof posterior to the frontal sinus, as shown 
in Fig. 147. In other cases a cell encroaches upon the floor of the frontal 



Fig. 146 



Fig. 147 





Showing a large bulla ethmoidalis (a) en- 
croaching upon the hiatus semilunaris; (b) the 
hiatus semilunaris.- The middle turbinate has 
been removed. (Dr. W. A. Fisher's specimen.) 



The anterior cell is the frontal sinus; the pos- 
terior one is one of the anterior ethmoidal cells 
extending half-way across the orbital cavity, 
and is inaccessible to operation except by bent 
curettes through the nasal chambers. The 
author recently operated on three such cases. 
(Dr. W. A. Fisher's specimen.) 



sinus and forms the so-called bulla frontalis, as shown in Fig. 148. The 
dense bone of the frontonasal spine of the superior maxillary bone 
often shields some of the most anterior of the cells from the curette. 
For these reasons the total exenteration of the anterior ethmoidal cells 
with the curette is not always possible by the intranasal route. As a 
consequence the frontonasal canal and the infundibulum cannot always 
be cleared of obstructive lesions. Drainage and ventilation of the frontal 
sinus are not, therefore, always possible by this method of operating. 

Should the subsequent course of the frontal sinuitis prove the inade- 
quacy of the operation, either the Halle, Good, or Ingals or one of the 
external operations is recommended. After an experience in more than 



THE AUTHOR'S OPERATIOXS WITHIN THE "VICIOUS CIRCLE' 



209 



four hundred cases operated on via the "vicious circle" of the nose, 
I am convinced that but few cases of frontal and ethmoidal sinuitis 
require more radical surgical interference. In only 3 per cent, of the 
cases was it necessary to perform an external operation. As the infun- 
dibulum is the outlet of the drainage system of the sinuses comprised in 
Series I, and as the anatomical deformities of the septum, middle tur- 
binate, and bulla ethmoidalis often obstruct the drainage and ventilation 
of the infundibulum, it is a rational conclusion that if the obstructive 
anatomical lesion is removed, drainage will be restored and the infection 
and inflammation cured. 

Hemorrhage is the most troublesome complication attending this 
operation. The parts are chiefly supplied by the anterior and posterior 
ethmoidal and a branch of the sphenopalatine artery (Plate I, Fig. 1). 
They are of considerable size and may bleed freely, though in my experi- 



Fig. 148 




Showing the nasal sinuses of the right side of the head. The naso-antral wall, inferior turbinate, 
and the middle turbinate are removed. One of the anterior ethmoidal cells (a) projects into the floor 
of the frontal sinus and forms the so-called bulla frontalis. (Author's specimen.) 

ence they rarely do so. The hemorrhage, though not profuse, usually 
continues for about twenty-four hours. A firm tampon of gauze in the 
upper portion of the nasal cavity readily checks it. Fortunately it is rarely 
necessary to introduce a tampon for this purpose. The presence of the 
tampon may prove as serious as the operation, as it may fracture the 
orbital plate and expose the orbital contents to infection. A tampon 
should not, therefore, be introduced except in case of severe hemorrhage. 
Drainage is of more importance than the control of a slight hemorrhage. 
Place the patient in a hospital if possible, as the hemorrhage can be kept 
under better control than it can if the patient is at home. 
' After-treatment. — Instruct the patient to introduce a pledget of cotton 
in the vestibule of the nose and to remove and renew it as often as it 
becomes soiled with blood and secretions. This protects the denuded 
surfaces from being irritated by the inspiratory current of air and prevents 
the blood trickling over the upper lip. A dusting powder of bismuth- 
14 



210 THE NOSE AND ACCESSORY SINUSES 

iodine should be insufflated once or twice daily. Healing usually occurs 
in about fourteen days, and if the exenteration is complete the space 
in the ethmoidal region should be free and roomy. For a few days after 
the operation small pledgets of cotton, saturated with a 10 per cent, 
aqueous solution of ichthyol, should be introduced every four hours into 
the attic of the nose to promote osmosis and asepsis of the surgical field. 

HALLE'S OPERATION ON THE FRONTAL SINUS 

Max Halle, of Berlin, secures entrance to the frontal sinus by the 
intranasal route by means of burrs and a protector to the internal plate 
of the frontal bone. The chief source of danger attending this operation 
is the injury of the internal plate of the frontal bone, thereby opening 
an avenue of infection to the meninges and brain. The grooved pro- 
tector is intended to prevent injury of this plate, and it should always 
be used. 

The anatomical barrier to the removal of the floor of the frontal sinus 
is the backward projection of the spina nasofrontalis of the superior 
maxillary bone. This dense, heavy bone was regarded as an insur- 
mountable barrier to the floor of the frontal sinus by the intranasal 
route, until Halle recently called attention to his method of operating. 

Indications. — The Halle operation is indicated in those cases of frontal 
and anterior ethmoidal sinuitis which have resisted the removal of the 
anatomical obstructive lesions within the " vicious circle" of the nose, 
and in which there is no fulminating symptom, as meningitis, orbital 
abscess, or external perforation. When these symptoms are present 
an external operation should be performed. (See How to Determine 
Which Operation Should be Elected.) 

Technique. — (a) Induce local anesthesia with cocaine. 

(b) Introduce a probe into the frontonasal canal for a distance of 
2\ to 3 cm. after it enters the infundibulum or hiatus semilunaris, as 
when it is passed upward and forward this distance it has entered the 
frontal sinus. 

(c) Introduce the protector beside the probe for the same distance. 

(d) Next engage the pointed drill (Fig. 149) against the under and 
posterior border of the spina nasofrontalis, just in front of the protector. 
Direct the drill forward and upward and remove enough of the bone 
to allow the blunt-pointed drill to be introduced. The sharp-pointed 
drill should only be used to make an opening large enough to permit 
the introduction of the blunt-pointed one, as to use it further might 
lead to injury of the internal plate of the frontal bone. The blunt drill 
will not do this. 

(e) With the blunt drill remove enough of the bone to permit the 
introduction of the pear-shaped drill (Fig. 150), the thickened portion 
of which is rounded and polished. According to Halle, the blunt or 
bulbous drill can inflict no serious injury to the meninges or brain, 
provided a little care is exercised. The entire floor can be drilled 
away with it, and so large a part of the external plate of the frontal 



HALLE'S OPERATION ON THE FRONTAL SINUS 
Fig. 149 



211 




Halle's frontal sinus drills and handle. 



Fig. 150 



Fig. 151 




Halle's first step in removing the nasal process 
-which forms the floor of the frontal sinus at 
its inner extremity. A metal protector (a) 
is introduced into the frontonasal canal to 
prevent injury to the inner or cranial wall of 
the frontal sinus. The pointed burr is only 
used to begin the operation, after which blunt, 
smooth-tipped burrs are used, as they will not 
penetrate the inner or cranial bony wall of the 
sinus if they should accidentally come in con- 
tact with it. 




The round-tipped burr removing the floor 
of the frontal sinus by the intranasal route. 
The protector is in position and the rounded, 
polished tip of the burr renders injury to the 
cranial wall of the sinus improbable. 



212 



THE NOSE AND ACCESSORY SINUSES 



Fig. 152 



bone in a downward direction that the instrument can be felt from 
without. It is necessary that the assistant take the precaution to push 
his finger well into the orbit, so that he can control the head of the 
instrument (drill) and prevent it going too far to the front or the sides. 

The mucous membrane of the frontal sinus may thus be exposed to 
ocular inspection and treatment through the nose if enough of the bone 
is removed, as shown in Fig. 152. 

(/) The after-treatment consists in first packing the sinus with iodo- 
form gauze, and the subsequent use of alcohol, protargol, or the nitrate 
of silver to retard granulations and to promote the formation of epithe- 
lium. At a later period Halle instructs the patient to introduce a large 
cannula several times a day to prevent the formation of granulations and 
adhesions, though this should preferably be done by the removal of the 
granulations, caustic applications, etc., by the surgeon. 

(g) The anterior ethmoidal 
cells and middle turbinated body 
of the "vicious circle" are also 
removed in this operation. The 
posterior cells may also be re- 
moved at the same time by either 
of the methods described else- 
where in this chapter. 

Good's Operation.— The first 
step of this operation is the re- 
moval of the anterior portion 
of the middle turbinated body, 
a procedure which, as I have 
shown, will often effect a cure 
of the frontal sinuitis, especially 
if it is of the simple catarrhal 
type, and is characterized by 
exacerbations of acute coryza. 
The second step of the opera- 
tion consists in the introduction of the guard and guide into the fronto- 
nasal canal (Fig. 153, b). The guard should have the normal curve of 
a frontal sinus probe or cannula, and is introduced with the same tech- 
nique. 

The third step of the operation consists of the introduction of the 
curved frontal sinus rasp into the frontonasal canal, in front of the 
guide, which is slightly hollowed or grooved. It may be necessary to 
use a little force, as the canal is too narrow to admit the rasp without 
crushing some of the anterior ethmoidal cells along its outer side. The 
rasp should be introduced until its tip emerges in the cavity of the 
frontal sinus (Fig. 153). The file-edge of the rasp should face anteriorly 
and outward, while the smooth surface should face posteriorly and 
medianward. The object of the rasp is to enlarge the frontonasal canal 
by removing some of the anterior ethmoidal cells, and to remove the 
floor of the frontal sinus. 




The intranasal operation of Halle completed. 
The floor of the frontal sinus is widely opened 
and permits curettage and free drainage of the 



GOOD'S OPERATION ON THE FRONTAL SINUS 



213 



After-treatment. — 'When the frontonasal canal has been enlarged and 
the floor of the frontal sinus removed, the wound may be maintained in a 
patulous condition by the use of a gold filigree tube, or, if a sufficiently 
large opening is made, the tube may be omitted. When the tube is not 



Fig. 153 




Good's intranasal frontal sinus operation, a, Good's rasp removing the floor of the frontal sinus; 
b, the guide and protector in position. 

used the area should be closely watched for exuberant granulations, 
which, if found, should be reduced with a bead of fused chromic acid 
crystals. The frontal sinus should be irrigated daily with boric acid 
solution until the purulent secretion ceases. 



Fig. 154 



- mwmmmW miBRmmitMt mm 







Good's rasps and chisels. 



This operation should not be undertaken unless it has first been 
demonstrated that a frontonasal probe will enter the frontal sinus via 
the frontonasal canal. If this cannot be done the rasp file might be 
misdirected, the posterior wall of the frontal sinus penetrated, and 
meningitis incited. 



214 THE NOSE AND ACCESSORY SINUSES 

The Ingals Operation. — According to E. Fletcher Ingals, the author 
of this operation, from 95 to 98 per cent, of all cases of empyema of the 
frontal sinus may be cured by his operation. This accords with the 
results obtained by my intranasal operations. (See "Vicious Circle" of 
the Nose and the Exenteration of the Middle Turbinate and the Eth- 
moidal Cells en masse, and the various operations upon the tissues within 
the area of the "vicious circle".) As my experience broadens I am 
inclined to modify my original opinion as to the percentage of cures by 
operations via the intranasal route. I still believe, however, that a large 
percentage can be cured in this way. 

The objections offered to the Ingals operation are: (a) That the internal 
plate of the frontal sinus may be injured, which would give rise to menin- 
gitis, though the guard and guide now used with the instrument will 
probably prevent such an accident, as with it the burr may be drawn 
forward away from the internal plate; (b) injury of the fossa ethmoidalis, 
which is a point in the anterior fossa near the cribriform plate, to which 
the dura is closely adherent, and which is regarded as especially sus- 
ceptible to meningitis. 

The Technique. — Ingals has performed all his operations under cocaine 
anesthesia, though a general anesthetic may be administered. The 
cocaine (20 per cent, in 2 to 1000 adrenalin) is injected into the fronto- 
nasal canal with a small curved cannula fitted to a hypodermic syringe. 
The cannula is inserted by the same technique which is used in prob- 
ing the canal to the floor of the frontal sinus. From J to Jn^ is then 
injected, the cannula slightly withdrawn, and the same amount again 
injected. This process is repeated until the whole length of the fronto- 
nasal canal is cocainized. Two or more introductions of the syringe- 
cannula may be necessary to produce complete anesthesia. 

If the anterior end of the middle turbinate has not been previously 
removed this region should also be cocainized. 

1. Remove the anterior end of the middle turbinate. This should 
be done two or more weeks before the Ingals operation, or else just 
preceding it, preferably the former, because this procedure alone is 
sometimes followed by a cure of the empyema of the frontal sinus. (See 
"Vicious Circle" of the Nose.) 

2. Introduce the probe-pilot into the frontonasal canal. 

3. Slip the pilot-burr over the probe-pilot until the burr is at the 
lower extremity of the frontonasal canal. If it is desirable to protect 
the internal plate of the frontal bone from injury, the pilot-burr may be 
protected by a guard, as shown in Fig. 155. With this device the pilot- 
burr may be drawn forward, away from the posterior wall of the frontal 
sinus. 

4. When all the parts of the instrument are adjusted the burr is gently 
pressed upward. It usually cuts its way into the frontal sinus in two or 
three seconds. It may be passed up and down through the opening 
thus made two or three times to insure a clear passage. 

5. Introduce a one-inch strip of sterile gauze saturated in a 20 per 
cent, solution of the chloride of zinc into the enlarged frontonasal canal, 



INGALS' OPERATION ON THE FRONTAL SINUS 



215 



having previously swabbed the nasal mucous membrane with vaseline. 
Leave the gauze in place for about five minutes, to insure its caustic 
action. The gauze should be introduced through a suitably curved 
uterine packer. 

6. A gold drainage tube is introduced into the enlarged frontonasal 
duct as follows : 

The wire applicator of the uterine packer is first enveloped with a 
flexible spiral shield. The drainage tube is then slipped on the end of the 
applicator and introduced into the lower opening of the canal. The 
spiral shield is then pressed upward against the drainage tube, forcing 



Fig. 155 




The Ingals intranasal frontal sinus operation: 1, the pilot-probe over which the pilot-burr is 
placed; 2, the pilot-burr; 3, the guide with which the pilot-burr is drawn forward away from the 
posterior wall of the frontal sinus; 4, the flexible shaft; 5, the frontonasal canal. 



it to the full depth of the canal. The applicator and spiral tube are 
withdrawn and the operation thus completed. Before introducing the 
gold drainage tube its spring ends are capped with a No. 2 gelatin 
capsule, which is further protected by a coat of vaseline to prevent it 
melting too rapidly when it comes in contact with the tissues. The cap- 
sule holds the flaring segments of the tube in position while it is being 
introduced. The capsule is dissolved in about five minutes and the 
segments of the tube spring apart and hold it in position. 

The tube should be worn for about four months, though to wear it 
for a much longer period would not cause great inconvenience. 

The frontal sinus should be irrigated daily through the tube. 

External Surgery of the Frontal Sinus. — On account of its location, 
the frontal sinus is sometimes less successfully treated by the intranasal 
route than either of the other sinuses. It is, therefore, necessary to 
resort to external methods of operating in a considerable number of 
chronic cases. The method of Hajek-Luc, or Ogston-Luc, as it is 
sometimes called, is one of the most efficient in uncomplicated cases of 



216 



THE NOSE AND ACCESSORY SINUSES 



chronic empyema of the frontal sinus. This method is not adapted, 
however, to those cases in which the anterior ethmoidal cells are to be 
exenterated. In such cases it is necessary to remove the floor of the 
frontal sinus and the processus frontalis of the superior maxillary bone 
to give access to the anterior ethmoidal cells. The posterior ethmoidal 
and sphenoidal cells are accessible by the intranasal route. 

The Hajek-Luc Operation. — (a) The skin of the forehead and around 
the eye should be thoroughly cleansed and covered with a moist dressing 
twenty-four hours previous to the operation. 

(6) The patient is placed upon the operating table and anesthetized. 

(c) The dressing is then re- 
Fig. 156 moved and the parts again 

washed. It is not necessary to 
shave the eyebrow, as it can 
be easily cleansed and is useful 
as a landmark; though I prefer 
to shave it, because it interferes 
with the removal of the stitches. 

(d) An incision is made, be- 
ginning at the temporal end of 
the eyebrow and extending to 
the bridge of the nose (Fig. 1 56) . 
A second incision may be started 
where the first leaves off, and 
extended upward as far as 
the upper limit of the frontal 
sinus, a fact which should 
be determined beforehand by 
skiagraphy. 

(e) The skin and periosteum 
within this triangular incision 
are turned upward, thus ex- 
posing the outer plate of the 
frontal bone. 

(J) A liberal portion of the 

bone is then chiselled away, 

thus exposing the frontal sinus 

to inspection and curettage. 

(g) After determining the outline of the sinus and the character 

and location of pathological lesions, the morbid material is removed 

with a curette, and if bonv septa are present thev are broken down 

(Fig. 156). 

(K) The frontonasal canal must be enlarged as much as possible, to 
establish free drainage into the nose. This is done by breaking down 
the anterior ethmoidal cells with a curette (Fig. 156), through the floor 
of the frontal sinus. 

(0 A large rubber tube is inserted into the enlarged frontonasal canal 
and left in position for several weeks, or until all discharge ceases. The 




The Hajek-Luc operation. The anterior wall of 
the frontal sinus is removed, and the anterior eth- 
moidal cells are being removed through the floor of 
the frontal sinus with a curette. The left side has 
been operated on, a gauze wick introduced through 
the anterior ethmoidal wound and drawn out 
through the nostril. 



EXTERNAL OPERATIONS ON THE FRONTAL SINUS 217 

nasal end of the rubber tube is seized with forceps from time to time, 
and moved up and down, to prevent adhesions. When all discharge 
ceases the tube is withdrawn through the nose. 

(j) After inserting the rubber tube into the frontonasal opening the 
external wound is closed and allowed to heal by primary intention. 

Advantages of the Operation. — The advantages of this method of 
operating are: (1) It avoids disfigurement, as the wound heals by primary 
intention; (2) the frontonasal canal is enlarged, the anterior ethmoidal 
cells eradicated; and (3) as they are invariably involved in frontal 
sinuitis, this operation is advantageous, because they are opened and 
drained in its performance. 

Disadvantages of the Operation. — Relapse occurs in about 50 per cent, 
of the cases, because the curettement cannot be done thoroughly, as 
the ethmoidal cells are not accessible through the frontal wound. Sup- 
puration of the scalp has been reported, and the operation has been 
followed by sinuitis on the opposite side. Severe intracranial complica- 
tions have also been reported. Tilley cites one death in 5 cases. 

Lermoyez reports 9 cases in which there were 8 relapses ; 5 of the cases 
were subsequently cured by Kuhnt's operation, 1 by the repetition of the 
Hajek-Luc operation, while 2 died of meningitis (slow septicemia). It 
appears, therefore, that this method, while apparently very simple, is 
sometimes followed by very serious sequelae. In view of these facts, it is 
usually better to adopt Kuhnt's operation, or at least a combination of the 
two. I believe this operation fails in such a large percentage of cases 
because the obstruction in the "vicious circle" of the nose is not removed; 
indeed, it is probable that this latter procedure alone would have given 
far better results than that given in the above statistics for the Hajek-Luc 
operation. 

Kuhnt's Operation. — The object of Kuhnt's operation is to obliterate the 
frontal sinus by granulation from the bottom of the cavity. He resects 
the entire anterior wall (Hajek-Luc removes only a portion of it) and a 
portion of the floor or superior orbital wall. Curettement is thoroughly 
performed, but the frontonasal canal is not disturbed, as to do so he 
thinks may lead to reinfection of the sinus from the nasal fossa. Kuhnt 
does not close the external wound, but leaves it open for the intro- 
duction of the dressings and for drainage. A cure takes place in from 
three to six weeks. Relapse and sequelae, according to Kuhnt, are rare, 
and recovery is the rule. 

Disadvantages. — (1) External drainage and dressings must be con- 
tinued for several weeks. (2) When a cure is accomplished the patient 
is more or less disfigured. (3) The anterior ethmoidal cells are unopened, 
though they are always simultaneously involved. (4) Diplopia has 
frequently followed, from injury of the pulley of the superior oblique 
muscle, or from inflammatory infiltration about the pulley or within 
the muscle. 

The Kuhnt-Luc Operation. — This operation is a combination of the 
method of Kuhnt and Hajek-Luc, and consists in the free removal of 
the anterior wall of the frontal sinus, the enlargement of the frontonasal 



218 THE NOSE AND ACCESSORY SINUSES 

canal, and the introduction of the funnel-shaped rubber tube, together 
with the closure of the primary skin incision. This gives a fairly good 
cosmetic result with frontonasal drainage and a partial ablation of the 
anterior ethmoidal cells, as in the Hajek-Luc operation, while it avoids, 
in a measure, the disfigurement attending external drainage, as practised 
by Kuhnt. There is more or less depression of the skin, w T hich is caused 
by the removal of the bone, but this can be corrected, in a measure, by 
subsequent paraffin injections. 

Kuster's Osteoplastic Operation. — A modification of the operation just 
detailed consists of making an osteoplastic flap instead of chiselling 
away the outer bony wall. The bony flap is formed by making a narrow 
incision with a V-shaped chisel along the upper border of the supra- 
orbital ridge for the whole length of the sinus. The incision is then 
extended upward into either end of the supra-orbital incision in directions 
corresponding to the outline of the sinus as shown by a skiagraph pre- 
viously made. This incision may also be made with a narrow-bladed 
rongeur forceps, or the De Vilbiss bone-cutting forceps. After the bony 
incision above the supra-orbital ridge is made it is enlarged somewhat 
at either extremity to admit two rongeur forceps by means of which 
the bony plate is broken off and left attached to the soft tissue above. 
Considerable care must be exercised in handling the bony flap and soft 
tissues while they are being retracted, lest they be separated. The 
next step in the operation consists of the incision of the membranous 
lining of the sinus and the removal of the floor of the sinus. This is 
followed by a very thorough curettement of the anterior ethmoidal 
sinuses through the floor of the frontal sinus. After carefully cleansing 
the sinuses the wound is packed with gauze moistened with the compound 
tincture of benzoin. The external wound is closed with sutures, and on 
the fifth or sixth day two of the centre stitches are removed and the 
dressing taken out. 

The object of this method of operating is the same as that of Kuhnt's 
operation. The eye symptoms are also the same. As Canfield has 
pointed out, there may be some deformity on account of the osteoplastic 
flap being lifted outward at its lower border by adhesions at the upper 
border of the bone flap to the posterior wall of the sinus, and subsequent 
contraction of the same. Again, the lower border of the osteoplastic 
flap is lifted outward somewhat by the removal of the gauze dressing. 
The lower border of the osteoplastic flap thus dislocated sometimes forms 
a ridge, which may be removed or corrected by a secondary operation. 
I see no reason why the wound should be packed as described. A better 
plan would be to pass a small wick of gauze through the enlarged fronto- 
nasal opening, to maintain its patency for a few days, and then to with- 
draw it altogether. This would obviate opening the external incision, 
as recommended, and would give a better cosmetic effect. A thorough 
exenteration of the anterior ethmoidal cells and the establishment of 
good drainage as recommended by me will nearly always be followed 
by a cure of the disease without an external operation. (See "Vicious 
Circle.") 



EXTERNAL OPERATIONS ON THE FRONTAL SINUS 219 

Beck's Double Osteoplastic Operation. — The method of procedure is 
as follows (for Indications see How to Determine Which Operation 
Should be Elected) : 

1. An incision is made through the skin and subcutaneous connective 
tissue through the upper margins of the eyebrows, then downward and 
inward as far as is usually done in the Killian operation. These two 
incisions are then joined by means of a transverse incision across the 
bridge of the nose. 

2. This skin and subcutaneous flap are then dissected upward until the 
upper limits of the frontal sinuses are exposed. This is determined by 
means of a celluloid tracing of the radiogram placed upon the frontal bone. 

The Preparation of the Celluloid Tracing. — Take a piece of ground 
celluloid film, about three inches square, place over the radiogram (glass 
plate) negative, which is either in the transilluminating box or against 
a window glass. Trace the outlines of the sinuses with ink. The outline 
of the supra-orbital margins is made for the purpose of getting a fixed 
point. The celluloid model can be sterilized in bichloride of mercury 
and alcohol. 

If the sinuses extend very high on the forehead, it may become 
necessary to make two small perpendicular incisions at the extreme 
limits of the flap over the external canthi. 

3. Place the -celluloid tracing of the radiogram over the frontal region 
and incise the periosteum all around the upper and lateral margins of the 
same, but not over the supra-orbital borders or at the root of the nose. 

4. With a flat chisel the external table of the frontal sinus is then 
penetrated along the whole course of the above described tracing through 
the periosteum; this also severs the attachment of the septum of the 
frontal sinuses from the posterior surface of the external table. 

5. This osteoperiosteal flap is then slightly pried open by means of 
a chisel, and a Gigli saw is inserted beneath the bone flap and carried 
down to its supra-orbital attachment. 

6. The saw should be made to cut from within outward; a few strokes 
severing the bone, care being taken to preserve the periosteum intact. 
Great care must be taken not to cut through this structure; indeed, the 
entire thickness of bone should not be sawn through, as it will readily 
break when it is everted downward over the nose. The skin flap is then 
reflected upward and the periosteal bone flap downward, thus exposing 
both frontal sinuses. The right side (Fig. 157) shows the granulations 
removed, and the drill in operation enlarging the frontonasal canal. 
The left side shows the cavity filled with granulations and pus. 

7. If only one sinus is to be exposed, the technique varies only in the 
osteoperiosteal flap, and in making the incision within the limits of the 
frontal sinus septum and the lateral limit of the sinus. The skin flap 
may be made by making a perpendicular incision from the internal 
angle of the orbit to the height of the frontal sinus, as indicated by the 
radiogram. 

8. Thoroughly eradicate the diseased mucous membrane, but do not 
curette it; and enlarge the natural opening into the nose, using the 



220 



THE NOSE AND ACCESSORY SINUSES 



Halle trephine or Good's rasp for this purpose. Also remove the most 
anterior ethmoidal cells as completely as possible through the floor of 
the sinus. This can only be done completely by opening through the 
lateral wall of the nose, as in Killian's operation. This constitutes the 
weakness of Beck's operation. 

9. Introduce a large rubber tube with a wick of gauze in its lumen 
into the enlarged frontonasal canal. The upper end of the wick is 
loosely folded within the cavity of the frontal sinus, while the other end 
is brought down to the floor of the nose, so that a small portion protrudes 
through the vestibule. 



Fig. 157 




Beck's osteoplastic operation upon the frontal sinus. The right side shows the probe in the 
frontonasal duct, and the frontal sinus freed of granulations and pus. The left sinus is still filled 
with granulations and pus. 



10. Replace the osteoplastic flap in its natural position. Bring the 
skin flap to its natural position and suture with silkworm gut, using 
the Halsted subdermal suture, with a few horsehairs, over the bridge 
of the nose. 

The After-treatment — The gauze should be removed on the day 
following the operation and on the third or the fifth day a gold or silver 
filigree tube should be inserted. In one case Dr. Beck used no tube, 
and four months after the operation the opening was sufficiently large 
to permit ventilation and drainage, the patient finally recovering. 

The use of douches and blowing the nose should be avoided for 
several days after the operation. Indeed, the patient should snuff the 
secretions from the nose. 



EXTERNAL OPERATIONS ON THE FRONTAL SINUS 



221 



If this operation fails it may be converted into the Killian operation 
at a subsequent time. 

Fig. 158 




Killian's incision, with cross-cuts for guides in suturing. 
Fig. 159 




Showing the retraction of the skin flaps in the Killian frontal sinus operation: P, the periostea] 
incision 5 mm. above the skin incision; S, the skin incision 5 mm. below the periosteal incision; 
P 1 , the periosteal incision at the side of the nose. 

The Killian Operation (for Indications see How to Determine Which 
Operation Should be Elected). — Technique. — After having prepared the 
field of operation, and having administered a general anesthetic, an 
incision is made through the eyebrow (previously shaved), beginning at 



222 THE NOSE AND ACCESSORY SINUSES 

its temporal end, extending to the median line at the root of the nose, 
and then curving downward and outward below the base of the nasal 
bone (Fig. 158). 

The periosteal incisions are two in number. The upper one is made 
parallel with the supra-orbital margin and 5 mm. above it, and extends 
from the temporal end of the incision to the median line of the nasal 
bones. The second periosteal incision begins internal to the attachment 
of the pulley of the superior oblique muscle (Fig. 159, p 1 ), passes inward 
and then curves downward and outward, following the direction of the 
incision of the skin around the inner canthus of the eye. This incision 
passes over the processus frontalis of the maxillary bone. 

Fig. 160 



The Killian frontal sinus operation completed: P, the periosteal incision 5 mm. above the 
superciliary skin incision; S, the superciliary skin incision 5 mm. below the periosteal incision; 
P 1 , the periosteum elevated and everted along the side of the nose. 

The soft parts, including the periosteum, are lifted from the bone, thus 
forming the skin and periosteal flaps, with the exception of the peri- 
osteum covering the superciliary ridge, where it is left intact to prevent 
the dislodgement of the pulley of the superior oblique muscle. 

The frontonasal process and a portion of the nasal bone are chiselled 
away, thus exposing the anterior ethmoidal cells, which are removed 
through the opening. The entire anterior wall of the frontal sinus is 
completely removed with a chisel and rongeur forceps (Fig. 160). 

The cavity of the sinus thus exposed should be thoroughly inspected 
and curetted in all its ramifications. Killian insists that when the an- 
terior bony wall is removed the mucous membrane should not at once 
be disturbed, but that it should be left intact as long as possible, so as to 



EXTERNAL OPERATIONS ON THE FRONTAL SINUS 223 

avoid unnecessary infection of the external wound. He makes a small 
preliminary opening through the bone, and then with a probe, introduced 
between the bone and mucoperiosteum, determines the limitations of the 
frontal sinus. A skiagraph, previously taken, would obviate the necessity 
of this procedure. Having done this, he proceeds to remove all the bone 
necessary for its complete exposure. He then opens the membranous 
sinus and proceeds to inspect and curette it according to the conditions 
present. All septa are removed. 

The next step in the operation consists in the removal of the floor 
of the sinus with a curette. As this operation is one wherein there is 
some danger of injuring the pulley of the superior oblique muscle, great 
care should be exercised to .avoid it. As the pulley is variously located, 
this is not an easy matter. Dr. Ostrum has devised a pulley marker 
(Fig. 161) which may be applied to the tissues marking the location of 
the pulley, so that in the event of its detachment it may be sutured to 
the marked point, and thus prevent strabismus. 

The opening around the processus frontalis may be enlarged upward 
and backward, to afford a better field for the curettement of the other 
sinuses, especially the ethmoidal and sphenoidal. Indeed, this opening 

Fig. 161 




Ostrum's localizer for the pulley of the superior oblique muscle, 

should be united with the one in the floor of the frontal sinus, as shown 
in Fig. 160. Still exercising great care not to injure the nasal mucous 
membrane, the surgeon should introduce the curette through the opening 
made by the removal of the processus frontalis, and perform the curette- 
ment of the ethmoidal and sphenoidal cells. The limits of the ethmoidal 
cells are not difficult to determine with the curette, as the septa between 
them are usually very thin and easily broken down. The bone of the os 
planum and of the cranial plate is of greater density and resistance, and 
need not be mistaken for the septa between the cells. Personally, I 
prefer to remove the middle turbinate and posterior ethmoidal cells by 
the intranasal route. I also open the sphenoid by the intranasal route. 

As the hemorrhage is considerable, the operator must depend upon his 
knowledge of the anatomical relations, the conditions of the diseased 
parts, and his sense of touch, rather than upon sight in exenterating the 
ethmoidal and sphenoidal cells. The wound should be thoroughly 
cleansed by irrigation with normal salt or boracic acid solution, then 
dusted with bismuth powder or bismuth paste, and the skin and peri- 
osteal incisions closed with sutures. 

A point in the after-treatment insisted upon by Killian is, that the 
patient should be placed upon his healthy side and forbidden to blow 



224 THE NOSE AND ACCESSORY SINUSES 

his nose. He must aspirate the secretions from the nose, and the nasal 
cavity should be inspected daily, carefully dressed, and exuberant granu- 
lations touched with nitrate of silver. If a double operation is performed 
the patient should lie upon his back and snuff the secretions from his 
nose. 

A few days after the operation, if pus still comes from the sinus, 
gentle pressure over the skin should be made to force it into the nasal 
cavity. The patient should not be allowed to blow his nose, as to do so 
might force infected matter from the nose into the frontal cavity. The 
deformity following the operation is usually of moderate degree, and 
often becomes less conspicuous after a few months. The frontal sinus 
becomes more and more filled with granulation tissue, and the orbital 
fat pushes upward through the open floor of the sinus. In this way the 
depression becomes fairly well filled, except when the sinus is very large 
and deep, in which case the disfigurement may be very great. 

This radical method of procedure is less likely to injure the pulley 
of the superior oblique muscle than the Kuhnt-Luc operation, or the 
Kuhnt operation, on account of the manner in which the periosteal 
incision is made, the periosteum over the superciliary ridge serving 
to hold the pulley in its place. 

Taking all the facts into consideration, if the case is complicated by 
ethmoidal and sphenoidal disease and an external operation is deemed 
necessary, the Killian operation is the most effective and least disfiguring 
of the external operations. 

Of one hundred and twenty-five cases of frontal sinuitis in which the 
clinical diagnosis was confirmed by skiagraphy, in only twelve (10 per 
cent.) did I find it necessary to perform the Killian operation, the others 
being cured by giving surgical attention to the structures within the 
"vicious circle" of the nose. Of the twelve Killian operations performed 
by me, ten resulted in cure, two did not, as I failed to remove all of the 
anterior ethmoidal cells at the primary operation. The deformity was 
almost nil except in one case. 



SURGERY OF THE MAXILLARY SINUS 

Intranasal Operations (for Indications see How to Determine 
Which Operation Should be Elected). — The intranasal surgery of the 
antrum may include (a) the structures within the "key," or "vicious 
circle," (6) the interior turbinated body and the naso-antral wall, and 
(c) the removal of the uncinate process. If the infundibulum is blocked 
by morbid tissue or by anatomical peculiarities, they should be removed. 
In exceptional cases this will be sufficient to establish a healthy con- 
dition of the mucous membrane of the sinus. If, however, the mucous 
membrane has undergone marked degenerative changes, it is usually 
necessary to perform an extranasal operation, as the Caldwell-Luc or the 
Denker operation, or, better still, the Canfield-Ballenger operation, 
which is equivalent to the Denker and is performed intranasally. 



SURGERY OF THE MAXILLARY SINUS 



225 



Removal of the Naso-antral Wall. — This operation was first performed 
by MyleSj and has had many advocates since then. Clinical experience 
has shown that a small opening in the naso-antral wall quickly closes, 
whereas a large one remains open permanently. Puncture and irrigation 
through a Krause cannula (Fig. 162) are often sufficient to effect a cure in 



Fig. 162 




Krause's antrum trocar with obturator. 

acute and subacute inflammation of the sinus. The puncture should 
be made beneath the inferior turbinated body. The canunla may be 
introduced daily under cocaine anesthesia, with little discomfort to the 
patient. The irrigating solution may range all the way from normal 
salt and boric acid solutions to the more irritating solutions of zinc and 



Fig, 163 




Vail's operation on the maxillary antrum. The fragment of the turbinate extending over the naso- 
antral opening should be removed with biting forceps. Vail prefers his method, whereby a portion 
of the inferior turbinate is removed with the saw. 



iodine. The usefulness of this procedure is largely limited to diagnosis, 
though it has some therapeutic value. 

Many instruments have been devised for the removal of the naso- 
antral wall, some of which enable the operator to do the work with ease 
and precision. The instruments which have given the best satisfaction 



15 



226 



THE NOSE AND ACCESSORY SINUSES 



are Vail's saw, O strum's forward cutting forceps, Wells' trocar and 
cannula rasp, Corwin's chisel, and Bishop's trephines. 

Vail's Operation.— Vail's is perhaps the most ingenious and practical 
method for the removal of the naso-antral wall. His saw is slightly 
curved upon the flat, and when introduced obliquely through the naso- 
antral wall, makes a circular or oval incision, thus removing a large 
portion of the wall (Figs. 163 and 164), separating the nasal chamber 
from the antrum. 

Fig. 164 




iftf^SS 




The removal of the naso-antral wall with Vail's convex saw. A mucous membrane flap is 
dissected from the naso-antral wall to be turned on to the floor of the antrum. 

Technique.— (a) Induce local anesthesia of the inferior turbinal and 
of the inferior and middle meatuses. 

(b) Remove the anterior half of the inferior turbinated body with 
the swivel knife or with scissors, or with the saw as it removes the naso- 
antral wall (Fig. 163). 

(c) Puncture the naso-antral wall near the floor of the nose with 
Vail's perforator. 

Fig. 165 




Vail's antrum saw. 



(d) Introduce the saw (Fig. 165) through the puncture and then make 
the circular or oval incision shown in Figs. 163 and 164. While the 
saw has a tendency to describe a circle, the size of the opening may be 
regulated by the operator, as the bone is thin. The opening should be 
made as large as possible, to overcome the tendency to close. 

(e) If a flap of mucous membrane is to be turned into the antrum to 
cover its floor, its anterior and posterior boundaries should be incised 



SURGERY OF THE MAXILLARY SINUS 



227 



with a right-angle knife. The upper boundary of the flap is made when 
the inferior turbinate is removed (Fig. 164). The mucoperiosteal flap 
should be separated from the bone with a small periosteal elevator. 
Having separated the flap, the saw is introduced and the button of 
bone removed as described in the preceding paragraph, after which the 
flap is turned on to the floor of the antrum, which has been previously 
curetted. The flap hastens the process of regeneration and epidermi- 
zation. 

(/) The first dressing consists of iodoform gauze loosely packed in the 
maxillary sinus. It should be removed in from twenty-four to forty- 
eight hours. 

(g) In the after-treatment gauze dressings should not be used. The 
cavity should be left open for drainage and ventilation. Every time the 
patient blows his nose he blows through the antrum. The case should be 
watched, and if exuberant granulations form, they should be promptly 
reduced by the application of dehydrated chromic acid crystals or with 
some other caustic. 

Fig. 166 




Corwin's antrum chisels. 



Fig. 167 




Corwin's operation upon the antrum: a, a, chisel making upper horizontal cut: b, b, lower 

horizontal cut. 



Corwin's Operation. — Corwin's chisels (Fig. 166) are admirable instru- 
ments for removing the wall. The projecting points enable the operator 
to engage them at an acute angle in the body wall. Chisels without 



228 



THE NOSE AND ACCESSORY SINUSES 



these points are not easily engaged, as they would glide over the surface 
of the mucous membrane (Figs. 167 and 168). 



Fig. 168 




Corwin's operation, second step, showing the chisel making the posterior perpendicular incision, 
the anterior one being already made. 

Ostrum's forward cutting forceps (Fig. 169) may be used after punc- 
turing the naso-antral wall at its posterior portion. It possesses the 
advantage of the forward cut, a point of no inconsiderable importance 



Fig. 169 




Ostrum's forward cutting antrum punch. 

in view of the fact that the anterior angle of the antrum is usually the 
seat of the greatest morbid lesion. Hajek's sphenoidal forceps may 
also be used for this purpose. 

Wells' combination antrum perforator and rasp file (Fig. 170) answers 
admirably for the purpose of making an opening in the naso-antral wall. 
After perforating the wall the sharp obturator is removed and the rasp is 
used to remove the remaining portion of the wall, which it does com- 



THE SURGERY OF THE MAXILLARY SINUS 



229 



pletely. The fragments of mucous membrane which remain are removed 
with sharp, biting forceps. 



Fig. 170 




Wells' trocar cannula rasp for removing the naso-antral wall. 

Bishop's trephine (Fig. 171), the Nobel-Cordes forceps (Fig. 172) 
and Stein's hand gouge or chisel (Fig. 173) are also admirable instru- 
ments for removing the naso-antral wall. 



Fig. 171 




The removal of the naso-antral wall with a trephine. 



With Stein's gouge two cuts are made: one beginning just posterior 
to the anterior attachment of the inferior turbinate and extending above 
its attachment to the posterior wall of the antrum, the other from the 
same point and extending backward along the floor of the nose to the 
posterior wall of the antrum. The two incisions thus make a large 
tongue flap, including the anterior half or two-thirds of the inferior 
turbinate. This is then removed with heavy forceps. It my hands this 
method of operating leaves the largest possible opening in the naso- 



230 



THE NOSE AND ACCESSORY SINUSES 



antral wall. The only objection to it is that by it too much of the 
inferior turbinate is removed. 

Extranasal Operations.— (1) Alveolar; (2) Kuster; (3) Caldwell-Luc; 
(4) Denker. 

1. The Alveolar or Cooper Operation. — The alveolar operation was for a 
long time a popular procedure. Tilley, of London, reports that of 300 
cases of antral disease seen during ten years, only one had sound teeth, 
and that of 27 cases drained by the alveolar route, 15 were obliged 
to use the tube and irrigation for from six months to ten years. Of 
these, 5 afterward elected the radical operation,, which was followed by 



Fig. 172 




Removing the naso-antral wall with the Nobel-Cordes forceps. 



Fig. 173 




Stein's antrum chisel or gouge. 



complete cure. Of 37 cases operated on by the radical method, 34 were 
successful. He also says that the alveolar route is indicated in recent 
cases (of a few months' standing) and in chronic cases as a preliminary 
measure. 

Of the alveolar methods, the removal of a carious tooth, usually the 
second bicuspid or the first or second molar, is attended with the most 
happy results. It is obvious, however, that this method is only applicable 
when there is positive evidence that the tooth is diseased beyond hope 
of repair. The conditions are rare, indeed, that justify the removal of 
a tooth that could be successfully treated by a dentist. Even should 



THE SURGERY OF THE MAXILLARY SINUS 231 

it be admitted that more perfect drainage can be obtained by the removal 
of a tooth, there are still other methods of establishing good drainage 
which do not require the interference with an important physiological 
organ, or other essential structure of the head. Drainage by the re- 
moval of a tooth should, therefore, be limited to those cases in which a 
competent dentist states that the tooth cannot be saved, or it can be 
demonstrated that there is a carious fistula extending from it to the antral 
cavity. In such cases the tooth may be removed, and the opening thus 
made enlarged and its walls rendered smooth. Daily irrigations with 
warm boric acid solution may be used until the discharge ceases. The 
alveolar opening should be closed with a strip of gauze, saturated with 
the compound tincture of benzoin, until healing occurs, or with a tube 
made for the purpose. 

2. The Kuster Operation. — This operation has been in much favor, as 
the interior of the antrum of Highmore is thereby exposed, permitting 
inspection and curettement of its cavity. The operation consists of the 
removal of the anterior wall of the antrum, as shown in the Caldwell-Luc 
operation. The opening is usually limited to the area of thin bone of the 
canine fossa, and should be large enough to admit the introduction of the 
index finger. With the head mirror, light is reflected into the cavity and 
its walls examined. The portion of the cavity which cannot be inspected 
should be thoroughly explored w T ith a curved probe. 

If necrotic areas and granulation tissue are found, they should be 
removed by thorough curettement. The preliminary step of the operation 
consists in the elevation of the upper lip and an incision at the labiogingi- 
val junction (Fig. 174). The incision is carried through the periosteum, 
and should be one and one-half inches in length. The periosteum is then 
dissected upward over the canine fossa and the upper lip pulled toward 
the eye with a retractor, after which the anterior wall should be removed 
with a chisel and rongeur bone forceps. The cavity should then be 
explored with a probe and the diseased mucous membrane and necrotic 
bone removed with the curette. If the antrum is divided by septa, they 
should be broken down to convert it into one large cavity. 

Having thoroughly removed the morbid tissue, the sinus should be 
loosely packed with gauze saturated with the compound tincture of ben- 
zoin. The end of the gauze should protrude through the labiogingival 
incision to prevent closure of the wound. If there is marked suppuration 
the cavity should be irrigated daily and a wick of gauze introduced to 
promote drainage. When complete healing has taken place the dressings 
are discontinued and the labiogingival opening allowed to close. This 
operation is not as good as the removal of the naso-antral wall, the 
Caldwell-Luc and the Denker operations. 

3. The Caldwell-Luc Operation. — This operation is, in most cases, 
preferable to the Kuster operation. By it the antrum is exposed as 
in the Kuster operation, and a large opening made through the naso- 
antral wall. The opening may be made with forceps, VaiPs saw, Corwin's 
chisels, or Myles' barbed cannulas through the nasal orifice. Preliminary 
to this, however, the anterior two-thirds of the inferior turbinal should 



232 



THE NOSE AND ACCESSORY SINUSES 



be removed. In making the naso-antral opening shown in Fig. 175, 
care should be exercised to avoid injuring the lacrymal canal which 
opens beneath and near the anterior end of the inferior turbinated 
body and passes forward and upward to the inner canthus of the eye 
(Fig. 177, 1). 

Having completed the removal of the canine and naso-antral walls, and 
having removed all diseased tissue from the antrum, the cavity should be 
lightly packed with a strip of gauze, the end of which is brought out 
through the nose. The labiogingival incision should be sutured (Fig. 
176) and allowed to heal by first intention. After the first dressing is 



Fig. 174 



Fig. 175 




The labiogingival incision in the Kuster and 
Caldwell-Luc operations. 



Applying the dressing after the Caldwell-Luc 
operation: a, the anterior or canine wall re- 
moved; c, c, the gauze wick in the antrum and 
extending through the naso-antral opening into 
the nasal chamber. 



removed it Is usually unnecessary to repack the antrum, drainage being 
very successfully accomplished through the naso-antral wound. At the 
end of the second day the gauze dressing should be removed through the 
nose. The secretions may be removed by forcibly blowing the nose and 
by irrigation. 

It has been claimed that it is unnecessary to do either the Kuster or 
the Caldwell-Luc operation, the simple opening through the naso-antral 
wall being quite sufficient. That the naso-antral opening is sufficient 



THE SURGERY OF THE MAXILLARY SINUS 



233 



in a number of cases is true. In other cases, in which a pronounced 
degeneration of the mucous membrane and caries of the bony walls of 
the antrum are present, it is necessary to do the Kuster operation first, 
and to explore the antrum by ocular inspection and curettement, a 
procedure which cannot be successfully done through the nose. The 
Caldwell-Luc operation should, therefore, be elected in those cases in 
which there is pronounced suppuration with granulation tissue or polypi 
in the middle meatus of the nose. If these procedures are properly 
carried out and the suppuration continues, it is probable that the 



Fig. V, 



Fig, 177 




Closing the labiogingival incision in the 
Caldwell-Luc operation: a, the euture; b, the 
Revidan needle. 



Showing the relation of the ductus lacrymalis 
to the inferior turbinated body: 1, the ductus 
lacrymalis; 2, the inferior turbinated body; 3, 
the maxillary sinus. (After Bardeleben.) 



ethmoidal and possibly the frontal sinuses are also involved, and that 
some of the secretions from them drain into the antrum. In that event 
proper attention should be given to the other sinuses. A skiagraph 
would prevent this mistake being made. 

4. The Denker Operation. — Indications. — This operation is indicated 
in obstinate inflammatory disease of the maxillary sinus, which does not 
yield to either the intranasal or to the Caldwell-Luc operation. In 
such a case the mucous membrane of the sinus may be very edematous 
and the seat of extensive granulations. 

The anterior angle of the sinus adjacent to the nose is often inacces- 



234 



THE NOSE AND ACCESSORY SINUSES 



sible to the curette, either through the nasal or the canine fossa wound, 
hence the failure of the intranasal and the Caldwell-Luc operations. 
As the edematous membrane and the granulations must be thoroughly 
removed to effect a cure, an operation should be adopted that will 

thoroughly expose the entire 

FlG " 178 cavity to curettement. The 

, Denker operation does it, and 

f it accordingly has a place in 

the treatment of selected ob- 
stinate cases. 

Technique. — (a) A general 
anesthetic should be given. 

(b) The patient should be 
placed in Rose's position, with 
the head hanging over the end 
of the table. 

(c) Postnasal tampons should 
be introduced to keep the blood 
from the throat and trachea. 

(d) The labiogingival incision 
should be made as in the Cald- 
well-Luc operation, but should 
extend to the median line. 

(e) Elevate the soft tissues 
and periosteum over the canine 
fossa. 

(/) Remove the anterior wall 
(canine fossa) of the maxillary 
sinus as in the Kuster and Cald- 
well-Luc operations, and then 
remove the bridge of bone between the canine fossa and the lower 
portion of the pyriform opening of the nose, as shown in Fig. 178. By 
thus extending the bony wound the anterior angle of the sinus is exposed 
to operative interference. 

{g) Through the opening thus made remove the edematous membrane 
and granulation tissue. 

(h) Elevate the mucoperiosteum of the inferior meatus of the nose, 
and of the inferior turbinated body, with a small flat elevator so curved 
as to adapt it to the anatomical configuration of the part. 

(i) Incise the mucoperiosteum thus elevated and convert it into a 
rectangular flap to be turned outward on the floor of the sinus. 

(j) Remove the bony wall and the anterior portion of the denuded 
inferior turbinated bone with bone-cutting forceps, the mucoperiosteal 
flap being turned into the nasal chamber to prevent injuring it with the 
bone forceps. The opening through the naso-antral wall should be 
quite large, as in the Caldwell-Luc operation. Otherwise it will soon 
become closed and defeat the purpose of the operation. 

(k) Turn the mucoperiosteal flap on to the floor of the sinus and 




The Denker antrum operation: a, the area of 
bone removed in the Kuster and the Caldwell-Luc 
operations. In the Denker operation additional 
bone is removed from b to the pyriform aper- 
ture. 



THE SURGERY OF THE MAXILLARY SINUS 235 

hold it in position for twenty-four to forty-eight hours with a bismuth 
gauze dressing. 

(/) The after-treatment, as in the Caldwell-Luc operation, consists 
in watching the case and reducing exuberant granulations with caustics 
as soon as they appear. 

o. Canfield-Ballenger Antrum Operation. — This is a radical, yet conser- 
vative, operation upon the maxillary sinus, wherein the inferior turbi- 
nated body is preserved intact. The operative technique upon the maxil- 
lary sinus has undergone so many changes during recent years that it is 
difficult to ascertain to whom the various points of technique are due. 
I shall not endeavor to review the development of antral operations, but 
shall limit my credit to those authors whose technique or principles are 
somewhat allied to those in this operation. 

In general terms this operation consists in the removal of that portion 
of the naso-antral wall lying between the attachment of the inferior 
turbinated body and the floor of the nose, plus that portion lying ante- 
riorly to the anterior end of the inferior turbinated body (Fig. 183, c). 
This is an elaboration of the old and well-known Mikulicz operation, 
in which but a small portion of the wall was removed. As a small open- 
ing soon closes by granulations extending from its borders, it is only 
suited to the relief of acute suppuration of the antrum. In order to 
adapt the operation to chronic suppurative processes, various operators 
have modified the operative technique, so as to remove a larger 
portion of the naso-antral wall. Most of them have sacrificed the 
anterior half or two-thirds of the inferior turbinal in order to render 
the naso-antral wall accessible to instrumentation. While this technique 
gave the desired access to the antrum by the nasal route, it possessed 
two vital defects, namely: (a) The inferior turbinal, a vital functionating 
respiratory organ, was largely destroyed, and (b) it failed to afford access 
to the anterior angle of the antrum, a region often most prominently 
affected by the disease. Hence, in those cases in which the whole mucous 
membrane of the antrum had undergone polypoid degeneration, or was 
the seat of edematous granulations, and required curettement or other 
treatment, this method of operation was inadequate. 

The Caldwell-Luc operation, which consists of the removal of a por- 
tion of the anterior wall of the antrum, and a portion of the naso-antral 
wall and inferior turbinal, was for many years the most radical procedure 
in vogue for the cure of chronic maxillary sinuitis. Radical as it was, it 
still failed to give adequate access to the anterior angle of the antrum, and 
the inferior turbinal was sacrificed. Denker's operation was more satis- 
factory, as by it the entire anterior wall of the antrum was removed, thus 
exposing the anterior angle of the antrum to curettage. The operation 
is, however, objectionable in two respects, namely: (a) The major portion 
of the inferior turbinated body is destroyed and the approach to the canine 
fossa (anterior wall) is via a labiogingival incision, thus necessitating 
the use of a general anesthetic. These objections hold equally well 
against the Caldwell-Luc operation. 

Hirsch, of Vienna, overcame one of the objections to the older forms of 



236 THE NOSE AND ACCESSORY SINUSES 

operation by preserving the inferior turbinated body. He does an intra- 
nasal operation under cocaine anesthesia. He resects the anterior half 
of the inferior turbinated body at its attachment to the naso-antral wall 
and lifts the resected portion upward in the nasal chamber by means of a 
thread in the hands of an assistant. With the naso-antral wall thus 
exposed, he proceeds to resect it from the floor of the nose to the line of 
attachment of the inferior turbinated body above. He does not, however, 
remove that portion of the naso-antral wall anterior to the anterior end of 
the inferior turbinated body, hence the anterior angle of the antrum is not 
exposed. Having removed a portion of the naso-antral wall he replaces 
the inferior turbinated body and retains it in position with a single stitch 
at its anterior end. 

Canfield, of Ann Arbor, first conceived the idea of entering the anterior 
angle of the antrum via the anterior naris under local anesthesia. His 
operation is in most essentials like the Denker; that is, he removes the 
anterior wall of the antrum, and after elevating the mucous membrane 
on the median side to the attachments of the inferior turbinal, resects 
the naso-antral wall, leaving the elevated mucous membrane, which he 
uses later as a covering for the floor of the antrum. He also elevates 
the mucous membrane on the outer aspect of the inferior turbinal to 
increase the size of the flap, which is to be reflected on to the antral 
floor. The only objection to this operation is the destruction of the 
anterior half of the inferior turbinated body. Many others have devised 
modifications of the foregoing operations, but none have succeeded in 
overcoming all the objections involved in the technique. 

I shall endeavor in the following paragraphs to direct attention to 
a method of operating which is at once radical enough to meet the 
requirements of the most severe chronic involvement, and conservative 
enough to satisfy the most critical, in that it preserves the inferior tur- 
binal intact at all times during and after the operation. By it the anterior 
wall of the antrum may be removed as in the Denker operation, the 
anterior angle of the antrum and all other portions of the antral walls 
exposed to inspection, curettement, and other treatment without impair- 
ing the integrity of the inferior turbinated body. The operation is a slight 
modification of the Canfield operation as originally described by him. 

Technique. — Anesthesia. — (a) Induce anesthesia of the nasal mucous 
membrane by the local application of cocaine or any other drug preferred; 
(b) induce anesthesia of the vestibular skin of the naris by the injection 
of Schleich's solution. This solution should also be injected beneath 
the periosteum of the canine fossa via the vestibule of the nose. 

Incision. — Distend the wing of the nose with a nasal speculum as 
shown in Fig. 179, a, to bring the anterior angle of the naso-antral wall 
into prominence. Then with a small scalpel make an incision the whole 
length of the exposed portion of the noso-antral angle (margin of the 
pyriform aperture (Fig. 180, b). Then elevate the membrane, includ- 
ing the periosteum over the canine fossa (Fig. 181). 

Opening the Naso-antral Angle. — The antrum should be opened via 
the naso-antral angle (margopyriformis) with rongeur bone forceps, as 



THE SURGERY OF THE MAXILLARY SINUS 



237 



shown in Fig. 181, c, or with a gouge and mallet. In some subjects the 
bone at this angle is dense, requiring considerable force to bite through 
it, while in others it is extremely thin and easily removed. While the 



Fig. 179 



Fig. 180 





Canfield-Ballenger operation: a, the margin 
of the pyriform aperture, the point of incision 
for the Canfield-Ballenger antrum operation. 



Canfield-Ballenger operation: b, the 
incision. 



Fig. 181 



Fig. 182 





Canfield-Ballenger operation: c, the naso- Canfield-Ballenger operation: d, the naso- 

antral angle removed, thereby exposing the antral wall being severed with the Wagener 
cavity of the antrum. forceps. 



incision extends higher than the attachment of the inferior turbinal 
(to allow retraction) the bone at the angles should only be removed below 



the line of attachment of the inferior turbinated bodv. 



In removing the 



238 



THE NOSE AND ACCESSORY SINUSES 



bone constituting the canine fossa, it is usually only necessary to remove 
enough to admit of the introduction of the Wagener antrum forceps as 
shown in Fig. 182, d. If, however, after making the opening through the 
naso-antral angle it is determined that the whole of the mucous membrane 
is not accessible to the curette, as much of the canine wall may be removed 
as will fully expose it. 

Fig. 183 




Interior view of the Canfield-Ballenger antrum operation: a, middle turbinal; b, line of attach- 
ment of the inferior turbinal, which is left intact; c, the naso-antral wall removed, extending from 
the floor of, the nose to the attachment of the inferior turbinal and from the anterior to the posterior 
limits of the antrum. 



Removal of the Naso-antral Wall. — The biting jaws of the Wagener 
forceps (Fig. 182) are placed astride the naso-antral wall and the wall 
bitten away from the attachment of the inferior turbinated body down 
to the floor (Fig. 183). This makes an opening about \\ by f inch in 
size. An opening of this size will never close by granulation. It was 
formerly thought necessary to remove the anterior half of the inferior 
turbinated body to expose the naso-antral wall to surgical interference. 
By this method it is rendered unnecessary, hence the inferior turbinal is 
unmolested and is preserved and continues to perform its respiratory 
functions. 

Immediate and After-treatment. — If the mucous membrane of 
the antrum is edematous and has not undergone polypoid or granulation 
degeneration it is not necessary to curette it away (Myles) . When such 
a pathological condition is present, packing the antrum with gauze moist- 
ened with the compound tincture of benzoin daily for three or four days 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 239 

will relieve the edema, and the mucous membrane will resume its normal 
structure and function. When, however, the mucous membrane is con- 
verted into large granulation masses or polypi, it should be thoroughly 
removed with a sharp curette, thereby denuding the bony walls. If 
this is done a new mucous membrane will not form, but the walls 
will become covered with thick fibrous tissue, which partially obliter- 
ates the antral cavity. Such tissue does not develop columnar 
epithelium, but continues to secrete a semipurulent fluid. For this 
reason, curettage should be avoided unless the pathological condition 
warrants it. 

After three or four days the gauze dressings should be discontinued. 
The cavity may then be swabbed or sprayed daily with a 10 per cent, 
solution of ichthyol to stimulate local hyperemia and leukocytosis (raise 
the resistance; raise the opsonic index), thereby hastening the reparative 
process. 

In conclusion, I wish to say that this method of operating is (a) radical, 
inasmuch as it fully exposes the cavity of the antrum to inspection and 
treatment; (6) it is conservative, as it is attended by the least possible 
destruction of physiological structures, particularly the inferior turbinal, 
which is neither temporarily nor permanently resected; (c) furthermore, 
the operation may be done under local anesthesia, whereas other opera- 
tions equally radical (and more destructive) must be done under 
general anesthesia; (d) the time required for this operation is much less 
than that for other radical operations. 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 

In some cases a single ethmoidal cell may be the seat of infection and 
inflammation, and it alone may require surgical interference. The bulla 
ethmoidalis is sometimes affected while all the other cells are apparently 
healthy. Less frequently one of the other ethmoidal cells is involved, or 
the anterior cells may be the seat of infection while the posterior cells are 
free from it, or the posterior cells may be affected and the anterior cells 
be normal. 

When the location of the infection has been determined, the middle 
turbinated body (middle concha), or a portion of it, may be removed 
and the exposed wall of the diseased cells broken down with a curette 
or a Griinwald biting forceps. The cells thus opened may close by 
granulation in the process of repair and thus necessitate repeated 
curettements before a cure is established. 

If after repeated attempts a cure is not effected, it may become 
necessary to perform a more complete operation. 

Turbine ctomy with the Author's Knife. — Inasmuch as the partial or 
complete removal of the middle turbinated body is frequently necessary 
to relieve muscular asthenopia (lack of balance of the extra-ocular or 
intra-ocular muscles), and to establish drainage and ventilation of the 



240 



THE NOSE AND ACCESSORY SINUSES 

Fig. 184 




Curettage of the ethmoidal cells after the removal of the middle turbinated body. The cutting 
edge of the curette is directed upward and removes the cells from the cranial plate as far forward 
as the dotted line. 

Fig. 185 




Curettage of the ethmoidal sinuses. Second step. The curette is turned outward against the 
orbital plate and breaks down the intercellular walls of the ethmoid cells, including the bulla eth« 
moidalis x and the line of attachment of the middle turbinated body. 

Fig. 186 




The author's right and left middle turbinal knives. 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 



241 



nasal accessory sinuses, I have endeavored to devise some simple means 
to accomplish it. The turbinotome (Fig. 186), herewith presented, in a 
measure solves the problem. 

Technique of Turbine ctomy. — (a) Cocaine anesthesia. 

(Jb) Introduce the curved blade of the knife beneath the middle tur- 
binate at the posterior extremity of the turbinated body (Fig. 187). 

(c) Then draw it forward along the line of attachment to the anterior 
end of the middle turbinate, thus removing it in its entirety (Fig. 188). 

(d) Remove the severed turbinate with dressing forceps. 



Fig. 187 




The first step of the removal of the middle turbinate with the author's knife. 
Fig. 188 




The removal of the middle turbinate with the author's knife. 

(e) As the anterior and posterior ethmoidal arteries supply the middle 
turbinate, hemorrhage may be free and persistent. If the patient is in a 
hospital, no dressing other than a dusting powder of bismuth or bismuth- 
iodine need be applied. If, however, the patient is at home, and is 
not easily accessible to the operating surgeon or his assistant, the space 
between the line of attachment of the turbinate and the septum should 
16 



242 THE NOSE AND ACCESSORY SINUSES 

be firmly packed with a strip of sterile gauze dusted with bismuth. This 
may be left in position for twenty-four hours. The nasal chamber 
should subsequently be kept free from secretions by frequent irrigations 
with sterile normal salt solution or by packing the nose lightly with a 
10 per cent, aqueous solution of ichthyol, which should be removed 
after twenty or thirty minutes. 

Meningitis has occasionally occurred after turbinotomy, probably on 
account of the tampon introduced. 

The Author's Method of Removing the Ethmoidal Cells and Middle 
Turbinal En Masse. — The operation for the complete exenteration 
of the ethmoidal cells en masse was devised by the author five years 
ago for the purpose of obtaining specimens for examination. He has 
long believed that a better understanding of the local pathology can be 
had where the diseased conditions are thus exposed than where the tissues 
are removed piecemeal or with a curette. He holds, also, that while 




i 

v b 

Lateral view of the middle turbinate and ethmoidal cells removed en masse by the author's 
operation - p, p, p, p, p, polypi; a, beginning polypoid degeneration. 

postmortem observations are valuable and instructive, those made 
upon specimens removed en masse from living subjects are much more 
so. With these motives in mind, he has endeavored to obtain material 
upon which to base conclusions concerning sinuitis complicated with 
polypoid growths in the ethmoid region. 

A Specimen. — The specimen shown in Fig. 189 consists of the right 
middle turbinated body, five posterior ethmoidal cells, the bulla eth- 
moidalis, and five polypi. Three of the polypi grew from beneath 
the anterior end of the middle turbinated body, above the hiatus semi- 
lunaris, just anterior to the upper anterior border of the bulla ethmoidalis. 
The other and smaller polypi were within the ethmoid cells. The fact 
that some of the polypi were concealed within the posterior ethmoid cells, 
illustrates the futility of removing the visible tumors only, and explains 
why the removal of the exposed growths is so frequently followed by 
the appearance of others in the same or in a closely related region. 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 



243 



Fig. 190 
Cribiform Plate 



The Author's Operation .—The general method of procedure is based 
upon the anatomical observation that the ethmoidal cells have but three 
planes of attachment (Fig. 190), namely: (a) To the anterior wall of the 
sphenoid bone, (b) to the cranial plate, and (c) to the outer or orbital 
wall of the nose. If, therefore, these three planes of attachment are 
incised, a large portion of the lateral half of the ethmoid body (including 
the posterior ethmoidal and one or more of the anterior ethmoidal cells, 
and the middle turbinated body) is detached within the nasal chambers 
from which it may be readily removed. 

The instrumentarium (Fig. 191) required for this operation con- 
sists of one instrument, supplemented by two others, which are only 
occasionally required. The important one consists of a short blade 
set at a right angle to a longer blade which is parallel with the shank 
of the instrument. The short blade makes the incision along the 
anterior wall of the sphenoid, and 
is then drawn forward and makes 
the incision along the cranial plate; 
when instrument is drawn forward 
the long blade makes the incision 
along the orbital wall and thus com- 
pletes the excision of the ethmoid 
cells and middle turbinated body. 

Technique. — (1) Anesthesia is in- 
duced by massage of the mucous 
membrane of the middle and supe- 
rior meatuses and the corresponding 
portion of the septum with a small 
cotton- wound applicator, the cotton 
being slightly moistened and dipped 
in powdered cocaine. The applica- 
tions should be made at intervals of 
from five to ten minutes to the areas 
previously named until complete 
anesthesia is induced. If preferred, 
the operation may be done under 
general anesthesia. 

(2) The exenteration is accomplished by the following procedures: 

(a) Introduce the author's ethmoid knife (Fig. 191) into the middle 
meatus, with the short blade turned upward until it impinges against 
the lower portion of the anterior wall of the sphenoid bone, or until 
it engages the posterior end of the middle turbinated body (Fig. 193). 
During this procedure the handle of the instrument is turned horizon- 
tally across the opposite side of the face (Fig. 192, position a). The 
short blade is then forced outward into the tissues in front of the 
sphenoid. 

This procedure is facilitated by moving the instrument backward and 
forward over a distance of about one-fourth of an inch, as these move- 
ments cause the short blade to penetrate the tissues to the depth of the 




Scheme showing the chief attachments of 
the ethmoidal cells (E, E) to the cranial plate 
of the frontal above and to the inner orbital 
walls on the outer aspect. It is obvious that 
if these planes of attachment are severed that 
the ethmoidal cells and the middle turbinates 
will be entirely detached. 



244 



THE NOSE AND ACCESSORY SINUSES 



orbital wall and thus cut the ethmoid cells from their attachment to the 
sphenoid body. These movements also engage the short blade behind 
the posterior end of the middle turbinated body. 

(b) The handle of the instrument is then rotated 45 degrees, to 
position b, Fig. 195. The short blade is then forced upward to the 
junction of the anterior wall of the sphenoid with the cranial plate, care 
being taken to have the long blade pass between the middle turbinated 
body and the outer wall of the nose. When the operator is assured that 
the blades of the knife are in their respective positions, he should work 
them upward parallel with the anterior wall of the sphenoid until the 
cranial plate is reached. The short right-angle blade should be forced 
upward in front of the anterior wall of the sphenoid until it strikes 
against the cranial plate, the long perpendicular blade resting against 
the orbital wall of the nose. The blades are not drawn forward as in 



Fig. 191 




The author's new ethmoid knives and curette. 



making a clean cut, but are wiggled or rotated slightly in their respec- 
tive axes. This is done in order to fracture the cell walls in front of 
the blades, which then readily cut the mucous membrane. The instru- 
ment is thus brought forward to the anterior attachment of the middle 
turbinated body (Figs. 193, 194, 195). 

(c) As the nasal chamber is quite narrow in its anterior portion, the 
handle of the instrument should be rotated another 45 degrees, to 
position c (Figs. 192 to 195). This turns the short right-angle blade 
downward into the nasal chamber and away from the septum. The 
knife should then be drawn forward and downward to complete the 
severance of the tissues. This being accomplished, the instrument is 
withdrawn through the vestibule of the nose. This movement of the 
instrument usually delivers the severed ethmoid mass from the nose; 
otherwise, it should be gently seized with forceps and withdrawn. 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 



24,5 



If it is found that the specimen is still attached to the nasal walls 
by some fibers, the blunt hook knife (Fig. 191) should be introduced 
between the specimen and the outer wall of the nose and the attachments 
severed with it. 



Fig. 192 




v ib 



Showing the three positions (a, b, c) of the ethmoid knife, in the successive steps of the author' 
exenteration of the middle turbinate and ethmoid cells en 



Fig. 193 



Fig. 194 




" : 




The first step of the author's exenteration 
of the middle turbinate and ethmoid cells and 
polypi en masse. The instrument in position 
a, Fig. 192. 



The second step of the author's ethmoidal 
operation. The instrument in position b, Fig. 
192. 



(d) The blood should be mopped from the nasal chambers, and the 
remaining fragments of cells should be broken down with the curette. 
This completes the operation. 



246 



THE NOSE AND ACCESSORY SINUSES 



The Dressing. — If there is serious hemorrhage the upper or ethmoidal 
region of the nasal chamber should be packed with a one and one-half 

inch strip of gauze impregnated 



Fig. 195 




The third and final step of the author's ex- 
enteration of the middle turbinate and the eth- 
moid cells en masse. The instrument in position 
c, Fig. 192. 



with the subnitrate of bismuth 
powder. The bismuth prevents 
decomposition and infection, and 
thus wards off the dangers of 
septic absorption. The gauze 
should be introduced against the 
anterior wall of the sphenoid, 
and folded and packed until the 
upper half of the nasal cavity is 
completely filled with it. Stout 
dressing forceps should then be 
introduced beneath the dressing, 
and the whole lifted in order to 
compress it into the area which 
has been operated on. The 
dressing should be removed in from one to twenty-four hours. The 
subsequent treatments consist in lightly packing the nose with cotton 
tampons saturated with a 10 per cent, aqueous solution of ichthyol or 
of argyrol. The applications should be repeated daily and left in place 
twenty minutes. This mode of treatment is more effective in removing 
the secretions and sterilizing the wounded surface than irrigations. 

Never introduce nasal tampons unless forced to do so on account 
of profuse hemorrhage, as they may cause infection and meningitis. 
Firmly packed dressings are dangerous. Personally, I rarely pack the 
nose, as I find severe hemorrhage rare. 

The Complications. — Hemorrhage. — (a) Hemorrhage nearly always 
attends the operation, and it may either persist, or appear later as a 
secondary hemorrhage, though the latter is comparatively rare. When 
we remember that the ethmoidal region receives its blood supply from 
the anterior and posterior ethmoidal and the sphenopalatine arteries 
the possibility of a severe hemorrhage is apparent. By packing the nose 
as described, this complication may be controlled. A slight sero- 
sanguineous oozing may continue for twenty-four to forty-eight hours 
in spite of the gauze packing, though it is of no serious consequence. 
If the patient is operated on in a hospital and remains there for three 
days, it will rarely be necessary to pack the nose. The activity incident 
to leaving the physician's office and going home increases the blood 
pressure, and, as a consequence, the chances of hemorrhage are greatly 
increased, whereas if the patient remains quiet in a hospital the danger 
is greatly diminished. 

(b) Emphysema of the Orbital Tissues. — The lamina papyracea of the 
orbital wall may be fractured in the operation, and upon blowing the 
nose may admit air into the cellular tissue of the orbit. This occurred 
twice in my practice, but in neither instance did it inconvenience the 
patient, as it disappeared in one or two days. 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 247 

(c) Orbital Infection, Cellulitis. — It is within the range of possibility 
for infection of the orbital tissues to occur subsequent to an ethmoid 
operation, though I have never observed it in an experience embracing 
four hundred operations. The orbital plate while thin is very resilient 
in the living, and is not easily fractured. 

(d) Meningitis. — Meningitis following the ethmoid operation is rare. 
The cribriform plate of the ethmoid and the cranial plate of the frontal 
bone are not easily fractured and in my experience have never been 
fractured. The chief point to be mentioned concerning them is that 
the operation should not be performed if a latent chronic meningitis is 
already present, as it may cause an acute exacerbation and extension 
which may prove fatal. The chief subjective symptom of latent men- 
ingitis is a severe headache. When this is present the operation should 
be postponed until it has been proved that it is not due to meningitis. 
If there is any doubt Quincke's spinal puncture should be made, some 
of the spinal fluid is withdrawn and subjected to the proper examinations. 
In one case of this description meningitis was demonstrated to be present. 

(e) Nasal Stenosis from Swelling of the Nasal Mucous Membrane. — 
This complication has occurred several times in my practice and has 
always been due to a partially severed fragment of the middle turbinated 
body which has been left in the nasal chamber. This was especially 
true of my earlier operations, in which I had not perfected the technique 
in its present form. Since performing the operation as described in this 
section, this complication has not occurred. 

I wish to say in conclusion, that the operation has given me greater 
satisfaction, and in properly selected cases has given better results than 
I have been able to obtain by any other method of operating. 

Mosher's Frontal-ethmoid Operation. — This operation may be per- 
formed under either local or general anesthesia. In my experience it 
has proved a most excellent and satisfactory procedure, and appears 
to be the simplest and safest operation devised for its purpose. While 
it will not replace the Killian frontal sinus operation, it will very greatly 
reduce the necessity for that operation. 

Technique. — 1. Cocainize the interior of the nose or administer a 
general anesthetic. 

2. Introduce a curette into the nasal chamber, until the cutting 
edge of the instrument facing the orbit is above the anterior attach- 
ment of the middle turbinate, as shown in Fig. 196. This area covers 
the frontonasal canal and the anterior ethmoidal cells draining into it. 
The bone at this point is usually very thin and easily broken down. In 
some cases the bone at this point is very dense, thus making it necessary 
to break through it more posteriority. Having located the instrument, 
make gentle but firm pressure toward the orbit, and at the same time 
withdraw it downward and forward one-fourth to one-half inch. A few 
such procedures with the curette will give the result shown in Fig. 197. 
The anterior ethmoidal cells are thereby completely opened. By 
continuing the curettage in a forward and upward direction the fronto- 
nasal opening in the floor of the frontal sinus is enlarged and free 



m 



THE NOSE AND ACCESSORY SINUSES 



drainage of this sinus established. The frontal sinus may now be 
entered with a blunt pointed frontal sinus probe, as shown in Fig. 197. 
Indeed, in most instances, a suitably bent, cotton-wound applicator 
may be easily introduced. 



Fig. 196 




Fig. 197 




3. The next step of the operation is the removal of the posterior 
ethmoidal cells. This is done with the same curette introduced through 
the opening already made, as shown in Fig. 198. The curette is intro- 
duced beneath the cranial plate and then brought downward between 



PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 



249 



the orbital and turbinal plates. This procedure is repeated several 
times until the anterior wall of the sphenoid is reached. 



Fig. 198 




Fig 199 




4. The turbinal plate, consisting of the superior and middle tur- 
binate bodies, is then seized with suitable grasping' forceps, and by 
gentle traction combined with twisting motions is detached from the 
cranial plate and removed from the nose. 



250 



THE NOSE AND ACCESSORY SINUSES 



5. The entire posterior and anterior ethmoidal regions are again 
examined by ocular and probe inspection, and all portions of cells 
remaining are removed. 

The after-treatment is the same as for any other method of opera- 
tion, my own preference being packing the nose daily with pledgets 
of cotton saturated with a 10 per cent, ichthyol or argyrol solution. 
The packing should be left in place about fifteen minutes. 



Fig. 200 



Fig. 201 






Moure's operation upon the anterior eth- 
moidal cells. The dotted line a indicates the 
area of bone removed from the lateral wall of 
the nose to expose the cells. 



Exposure of the anterior ethmoidal cells 
through the inner wall of the orbit. This 
method of procedure is adapted to those cases 
complicated by orbital cellulitis. 



EXTERNAL OPERATIONS UPON THE ETHMOID SINUSES 



Moure's External Ethmoid Operation. — This operation may be 
performed in those cases in which extensive necrosis and polypi are 
present in the ethmoidal region upon both sides, as it exposes the field of 
operation better than any other method. It may also be used to expose 
large tumors in this region. 

Technique. — (a) The operation should be performed under general 
anesthesia, though it may be done under local injections of Schleich's 
mixture combined with local cocaine anesthesia of the nasal mucous 
membrane. 

(b) Insert postnasal tampons, one in either nostril, to prevent the blood 
entering the trachea. 

(c) Make an incision along the ridge of the nose from a point midway 
between the eyebrows, extending downward to the nasal opening on 
the side to be operated on, at the junction of the cutaneous septum 
with the ala or wing of the nose. 



THE SPHENOIDAL OPERATION 251 

(d) Elevate the soft tissues, including the periosteum, as shown in 
Fig. 200. 

(e) Resect the nasal bone and the frontal processes of the maxilla, as 
shown in the area encircled by the dotted line (a) in Fig. 200. 

(J) AYhen the ethmoidal labyrinth has been thus exposed, the entire 
ethmoid region may be thoroughly exenterated with a curette. 

If the disease is well advanced, that is to say, if there are polypi and 
granulations, every vestige of the cells should be removed. The cranial 
plate, the os planum (paper plate of ethmoid) or orbital wall, and the 
lacrymal bone which is adjacent to the anterior cells should be gently 
but thoroughly curetted until they are smooth. In addition to these 
surfaces the ethmosphenoidal wall (posterior limit of the ethmoidal cells) 
should also be thoroughly curetted. If all these surfaces are cleared 
with the curette and the anterior and posterior ethmoidal labyrinths are 
separated from their attachments, the cells and the middle turbinated 
body may be removed through the nasal wound or through the anterior 
naris. 

(g) The space from which the cells have been exenterated may be 
packed with a strip. of gauze in front of the postnasal tampon on the 
side operated upon, and the postnasal tampon removed from the other 
side. 

(h) The skin and periosteal incision should be closed with fine silk- 
worm sutures. 

(i) Watch the case, and should granulations form at any point, touch 
them lightly with carbolic or chromic acid. Should points of suppuration 
be found, probing should be done, with a view to tracing them to their 
sources. If the cause is found to be a cell which, through error, was 
not removed, or which was inaccessible, as an anterior ethmoidal cell 
extending over the orbital cavity or a posterior ethmoidal extending to the 
lateral side of or behind the sphenoidal sinus, steps should be taken to 
maintain a patulous opening for drainage purposes. All granulations 
should be removed from the point of suppuration as rapidly as they 
appear. Persistent after-treatment as described above will often be 
rewarded by a cure of the case. 

Orbito-ethmoid Operation. — (a) Make the Killian incision and 
elevate the tissues and periosteum at the inner aspect of the orbit, as 
shown in Fig. 201. (b) Remove the nasoorbital plate of bone and curette 
the ethmoidal cells through the opening. The orbital tissues should also be 
explored and the pus evacuated if present. Maintain external drainage 
until the discharge ceases, and allow the wound to heal by granulation 
from the bottom. 



THE SPHENOIDAL OPERATION 

The preliminary operative procedure for reaching the sphenoidal 
sinus consists of the complete removal of the middle turbinated body, 
thus exposing the ostium sphenoidale to view. 



252 THE NOSE AND ACCESSORY SINUSES 

I use the Hajek or the Fletcher sphenoidal forceps because they are 
strong and remove the anterior wall completely. One of Hajek's forceps 
cuts upward and the other downward. Fletcher's forceps cuts in all direc- 
tions, as its biting end is a circular disk. The disk is conical on its distal 
aspect to enable the operator to force it through the ostium sphenoidale 
without first enlarging it, as is necessary in using Hajek's forceps. 
Fletcher's instrument is very powerful, and as it cuts in all directions is 
most admirably adapted to the surgery of the sphenoidal sinus; further- 
more, but one instrument is required. If the ostium sphenoidale is 

Fig. 202 




Removing the anterior wall of the sphenoidal sinus with the Hajek forceps. The distal blade 
of the forceps is introduced through the ostium sphenoidale and the bony wall removed by- 
successive bites. 

small it should first be enlarged with a curette. The upward cutting 
forceps should then be introduced and the upper portion of the wall 
removed. By turning the forceps to either side the lateral portion of 
the wall may be removed. Next introduce the downward cutting 
forceps (Fig. 202) and remove the lower portion of the wall. The 
wall near the floor of the sinus is quite thick, but is readily removed 
with Hajek's forceps. When the wall is entirely removed, the opening 
is often one-half by three-fourths of an inch in area, and the interior 
of the sinus may be inspected by reflected illumination. When the 
mucous membrane is normal it is pale, and by contrast with the nasal 
mucous membrane appears almost white. Under probe pressure, 
it is thin, firm, and slightly resilient. When diseased, it is more red, 
edematous, and thickened. In some cases the sinus is filled with granu- 
lation tissue or polypi. 

When the anterior wall is removed and the mucous membrane is 
diseased, it should be thoroughly curetted. 

The after-treatment consists of irrigations and the topical application 
of a 10 per cent, aqueous solution of ichthyol. As there is a marked 
tendency for the mucous membrane to reform over the opening in the 
sinus, it may be necessary to remove it from time to time to maintain 
ventilation and drainage. This is easily accomplished, as the middle 
turbinate has been previously removed and the tissue to be removed is 
membranous. The after-treatment may extend over many weeks. 



CHAPTER XII 

NASAL NEUROSES. NASAL HYDRORRHEA. CEREBROSPINAL 

RHINORRHEA 

NEUROSES OF OLFACTION 

The neuroses of olfaction are characterized by either (a) a perverted 
sense of smell (parosmia), (b) oversensitiveness to olfactory stimuli 
(hyperosniia), (c) a partial loss of the sense of smell (hyposmia), or 
(d) a total loss of the sense of smell (anosmia). 

Parosmia. — Parosmia is characterized by a perception of imaginary 
odors, and may be due to pathological changes in the olfactory brain- 
centre. Inflammatory disease of the mucous membrane in the attic 
of the nose may also produce parosmia by overstimulating the nerve 
endings. It usually accompanies lesions of the central brain, although 
it occasionally occurs in hysteria, hypochondria, epilepsy, insanity, and 
syphilis. 

Hyperosmia. — Hyperosmia is characterized by an oversensitiveness 
to olfactory stimuli — that is, the perception of odors is exaggerated. 
The most delicate perfumes or odors not ordinarily perceived are recog- 
nized even to the point of unpleasantness. In some cases the perception 
of odors persists after the source of the odor is removed, and in this 
respect the condition approaches parosmia. 

It may be due to an irritation of the olfactory lobes, hysteria, neuras- 
thenia, hypochondria, sexual disorders in women (especially at the 
menstrual period), and to the lowered nervous forces accompanying 
wasting diseases. 

Hyposmia. — Hyposmia is characterized by a partial loss of smell, 
either from an impairment of the mucous membrane of the attic of the 
nose, the nerve endings, the bulb, or the brain centre. The impairment 
is only great enough to obtund the perception of odors without totally 
destroying it. 

Anosmia. — Anosmia is characterized by a total loss of the sense of 
smell, the pathological lesion being more extensive than that found in 
hyposmia. 

I have often seen cases in which the total loss of smell was due to 
a blocking of the olfactory fissure by an enlargement of the middle tur- 
binate, which was relieved by its removal. These cases were also com- 
plicated by ethmoiditis and sphenoiditis, but the loss of the sense of 
smell was not due to the inflammatory disease, as the ability to perceive 
odors was immediately restored by the removal of the middle turbinate. 
If it had been due to disease of the mucous membrane, considerable 

(253) 



254 THE NOSE AND ACCESSORY SINUSES 

time would have elapsed before regeneration could have taken place. A 
cold in the head is a frequent cause of transient anosmia. 

Odors reach the attic of the nose by either the anterior or the posterior 
nares, hence any condition of the septum or of the tissues of the outer wall 
of the nose which blocks the anterior or posterior nares may produce 
anosmia. The lesion may be in the nerve endings, as in atrophic rhinitis, 
in the nerve, or in the olfactory brain centre. Anosmia of intranasal 
origin may be unilateral or bilateral according to the location of the 
obstructive lesion. In such cases the sense of smell may be restored by 
the proper surgical procedure within the nose. If, however, the lesion 
is in the olfactory nerve or brain centre a cure is scarcely possible. 



SENSORY, VASOMOTOR, AND REFLEX NEUROSES 

Hyperesthetic Rhinitis; Hay Fever. — JJyperesthetic rhinitis, or hay 
fever, is characterized by annual paroxysms of sneezing accompanied by 
a severe and prolonged coryza and asthma. 

Etiology. — The Predisposing Causes. — The predisposing causes of 
hyperesthetic rhinitis are constitutional, local, climatic, geographical, 
racial, and altitudinal. 

(a) The constitutional causes are a neurotic temperament, chemical 
changes in the glands which secrete mucus (D. Braden Kyle), and gout 
and rheumatism. 

The neurotic temperament is difficult to define, but seems to be an 
unstable condition of the nervous system, wherein there is either an 
excess or a decrease in the nervous energy. Some physicians claim that 
the nervous disturbance is due to a faulty metabolism whereby certain 
toxic substances are liberated in the blood current. Thus a gouty or a 
rheumatic diathesis is held to be the basic cause. It is obvious, however, 
that there must be a reason for the gouty or rheumatic expression. It 
appears impossible in the present state of our knowledge to define clearly 
the conditions which cause a nervous temperament. That hay fever 
subjects are neurotic is generally accepted. Why they are neurotic 
is a much mooted question, concerning which many ingenious theories 
have been advanced, but none of which are convincing. 

(b) The local causes of hyperesthetic rhinitis are various. A perfectly 
healthy nasal mucous membrane on a normally placed bony frame- 
work is not often affected by hay fever. On the other hand, an apparently 
healthy mucous membrane on a normally placed bony framework may 
be affected. I have seen cases in which there was no obstructive septal 
deformity and no absolute occlusion of the olfactory fissure by turbinal 
enlargement. The only noticeable morbid lesion was a slight redness 
of the mucous membrane over the anterior end of the middle turbinated 
bone. These cases were also subject to occasional attacks of severe 
coryza, with copious purulent discharge. During the interim between 
the attacks of coryza no symptoms were complained of, but an examina- 
tion of the nose showed the reddened and slightly boggy edematous con- 



SENSORY, VASOMOTOR, AND REFLEX NEUROJSES 255 

dition of the anterior portion of the middle turbinal. While I do not 
care to promulgate a new theory as to the etiology of hay fever, I have 
been impressed with the possible relationship of catarrhal sinuitis, 
particularly ethmoidal and frontal, to hay fever. In some cases the 
surgical treatment of the sinuitis was followed by a relief of the hay 
fever. It is possible that the catarrhal discharge so irritates the nasal 
mucous membrane as to make it susceptible to the irritation of the 
pollen of certain plants and grasses. The difficulties in the way of 
diagnosticating catarrhal sinuitis have been so great that it has usually 
been unrecognized. With our present knowledge its detection should 
be more often made. It is now possible to study the relationship 
existing between sinuitis and hay fever, and I have some confidence 
that such a relationship will be satisfactorily established. Indeed, 
since the publication of the foregoing statements in the third edition, 
I received a communication from Dr. P. M. Farrington, of Memphis, in 
which he refers to two cases of hay fever cured by autogenous vaccine. 
He used about 50,000,000 bacteria at the first injection (Case 1), 
and at the third injection used 100,000,000 without reaction. After 
the first injection there was great improvement, and after the second 
all symptoms, except a slight stuffiness of the nose, disappeared. The 
injections were given every fourth day. The second case was treated 
in the same manner and with the same excellent results. 

The late Dr. Schadle recently called attention to the possibility of 
relationship between maxillary sinuitis and hay fever. Whether or 
not such a relation exists, we must recognize the fact that the local 
hyperesthesia probably has an anatomical or inflammatory origin. 
The hypersensitiveness does not " happen," but has a definite cause. 
Inasmuch as sinuitis, either catarrhal or suppurative, is often asso- 
ciated with hay fever, it seems plausible to conclude that the irrita- 
tion attending the discharge of the secretions over the nasal mucous 
membrane may be the cause. The hypothesis is still further supported 
by the clinical fact that some cases of hay fever are cured by successful 
treatment of the sinuitis. 

While the above hypothesis is based upon clinical observations, they 
are too meagre to warrant final conclusions. They are sufficient, how- 
ever, to justify the closest scrutiny of the sinuses in every case of hyper- 
esthetic rhinitis (hay fever). Such a scrutiny should include the examina- 
tion of the middle turbinal, the olfactory fissure, and the septum; trans- 
illumination, and a skiagraph of the sinuses. In addition the patient 
should be closely questioned concerning the presence of headache (chiefly 
frontal), dizziness, especially upon stooping forward, and unilateral 
disturbances of the ocular apparatus. The ocular disturbances may 
include errors of refraction, ulcer of the cornea, or lesions of the retina 
or other portions of the optic tract, and of any other of the structures 
of the eyeball. The composite picture thus elicited should show con- 
clusively either the presence or absence of an associated disease of the 
sinuses. 

Deflection of the septum, especially in the region of the middle turbinate 



256 THE NOSE AND ACCESSORY SINUSES 

or enlargement of the middle turbinate, causing contact between the 
two, is another local factor in hyperesthetic rhinitis. 

The ''sneezing area" of the nose is at the points of contact between 
the middle turbinate and the septum, hence the sneezing which is so 
characteristic of this disease. As a rule, the sneezing ceases as soon as 
the pressure is relieved. 

Sensitive areas on the nasal mucous membrane of the septum and 
the outer walls of the nose, which are reddened and slightly elevated 
above the surface of the mucous membrane, predispose to the hyper- 
esthetic paroxysms. Whether they are due to some concurrent inflamma- 
tion of the accessory sinuses, or to some change in the sensitive nasal 
branches of the sphenopalatine ganglion, is not established. It is reason- 
able to suppose that an inflammatory disease of the nose, attended with 
an irritating secretion, which is characteristic of catarrhal sinuitis, might 
affect the filaments of the terminal sensitive nerve and render them 
extremely hypersensitive. The local vasomotor disturbance in the 
same areas would cause their elevation above the surface of the mucous 
membrane. 

Polypi have long been considered a local predisposing cause of hay 
fever. As these morbid growths are often secondary expressions of 
sinuitis, the possibility of the causative relationship of this disease is 
thereby strengthened. The polypi are usually found in the region of the 
hiatus semilunaris, the border of the middle turbinate, or the posterior 
ethmoidal cells. In the latter case they protrude through the olfactory 
fissure into the middle meatus or are lodged above the middle turbinate 
in the superior meatus. It is evident that the mere removal of the 
polypi may not suffice to eradicate the irritation. The diseased sinuses 
should also receive appropriate treatment. 

(c) The climatic influence upon hay fever is well recognized as being 
confined to the neighborhood of the forty-fifth parallel of the northern 
hemisphere. The territory a few degrees either north or south of this 
latitude is comparatively free from this disease. This is probably due to 
the absence of the flora, the pollen of which is the chief exciting cause. If 
a map of the United States were divided into four belts by lines drawn 
through it from east to west, the majority of the cases of hay fever would 
be included within the third belt from the bottom, although many cases 
would be found in the other belts. 

(d) The geographical distribution of hay fever is instructive. It is 
more prevalent in the United States than in any other country; England 
ranks second. It is also present in Germany and France, though in 
less degree. 

(e) The racial influence in the predisposition to hay fever is marked. 
It is more common in the English-speaking races of the northern hemi- 
sphere than among the French or Germans, though it is more or less 
prevalent among them. 

(/) Altitude has considerable influence in the causation of hay fever. 
The disease is more prevalent in the low portions of the country than in 
the higher altitudes, which are comparatively free from it. The annual 



SENSORY, VASOMOTOR, AND REFLEX NEUROSES 257 

pilgrimages which are made into the mountains in the northern portion 
of the Eastern States and into the cold, bracing atmosphere along the 
shores of Lake Superior and the northern shores of Lake Michigan are 
indicative of the benefits derived from altitudinal and climatic change. 

(g) Age is an important factor in the causation of hay fever; it is 
most common in persons between the twentieth and fortieth years of 
life. 

Exciting Causes. — It is generally believed that the exciting causes 
of hay fever or hyperesthetic rhinitis are the emanations from certain 
plants and animals. It was at one time thought that all cases were 
of vegetable origin in the haying season, hence the name. Subsequent 
observations have shown that the exciting cause may emanate from 
various plants and animals, chiefly the following: Graminacese, Solidago 
virgaurea (goldenrod), Ambrosia artemisisefolia (rag-weed), cats, dogs, 
horses, and cows. The emanations from grasses and other plants, 
which cause the paroxysmal symptoms, is probably their pollen. In 
1873 Blackley conducted a series of experiments with glycerin-covered 
glass plates and observed the rise and fall of the intensity of the symp- 
toms with the increase and decrease in the quantity of pollen within a 
given area on the plates. From these observations he proved that the 
pollen of certain plants was an exciting cause of the disease. Since then 
many observers have reported that the emanations from animals are 
also exciting causes. 

The season has a characteristic influence upon the occurrence of 
the paroxysmal attacks of hyperesthesia. This is due to the fact that 
there are no emanations from plants except during the time they throw 
off their pollen. The disease occurs most frequently in August and 
September and less frequently in June, when the roses are in bloom. 

An analysis of the causes of hyperesthetic rhinitis resolves the etiology 
into three groups, as follows: (1) A constitutional or neurotic habit. 
(2) Local morbid lesions of the nose and accessory sinuses. (3) The 
pollen of certain plants and emanations from certain animals. 

Pathology. — The structural changes in the affected nasal mucous 
membrane consist of hyperemia, edema, and (after repeated attacks) 
hyperplasia of the turbinated bodies. The presence of nasal polypi in 
a hay fever case is scarcely to be considered a pathological lesion of this 
disease, but rather a result of inflammation of the sinuses. The elevated 
hypersensitive areas are chiefly found at the terminal endings of the 
sensitive branches of the sphenopalatine ganglion, and are due to the 
increased hyperemia in these areas, while the hypersensitiveness is due 
to the irritation of the sensitive endings of the nerve fibers. 

If the disease w T ere a pure neurosis there would be other nervous 
phenomena somewhat proportional to the intense paroxysms of the 
hay fever, whereas if it were a true inflammatory disease there would be 
greater structural changes. The disease is probably a combination of a 
moderately severe neurosis, with local morbid changes which give rise 
to the local irritation of the nerve endings of the sensitive branches of 
the sphenopalatine ganglion, upon which, at favorable seasons of the 
17 



258 THE NOSE AND ACCESSORY SINUSES 

year, the pollen of certain plants and the emanations from certain animals 
lodge, and give rise to the phenomena characteristic of hyperesthetic 
rhinitis. 

Symptoms. — The symptoms of hay fever are those of an acute coryza, 
as malaise, elevation of temperature, sneezing, serous discharge, head- 
ache, etc., to which are added an itching in the region of the soft palate 
and the median palpebral commissures (inner canthi) of the eyes, and 
asthma. The sneezing is paroxysmal and may be excited by slight 
draughts of air, bright sunlight, particles of dust, and psychical impres- 
sions, such as the consciousness of being observed by another person, 
or the thought of his own condition. The sneezing is accompanied by 
profuse lacrymation and serous nasal secretion and by suffusion of the 
conjunctiva. The profuse serous discharge from the nasal mucosa is 
followed by a contraction of the swollen mucous membrane, which 
brings temporary relief. 

The serous secretion from the nose is acrid, and excoriates the alse 
of the nose and the upper lip. (I have observed the same phenomena 
in some cases of inflammation of the ethmoidal cells when pus was 
absent.) The secretions become seromucous and in some cases puru- 
lent in character. 

Intermittent and alternate stenosis of the nose is present. During the 
continuance of the nasal stenosis the patient suffers from the paroxysmal 
sneezing and asthma, and from headache, lacrymation, and diffidence. 
The diffidence is extreme, and the patient dreads the approach of another 
person, especially if he is a stranger or someone with whom he is ill at 
ease. 

The pharynx is often dry and painful upon deglutition. The tonsils 
are not usually inflamed, although they may be. 

Tinnitus aurium is frequently present, and is due to a swelling of the 
mucous membrane of the Eustachian tubes. 

The appetite is impaired, and there is a corresponding loss of weight. 

Prognosis. — A conservative prognosis should always be given. So 
many methods of treatment have been promulgated, with the assurance 
of success, and have proved wholly inadequate, that I doubt the value of 
nearly all of them. Upon theoretical grounds it appears that if either one 
of the three major causes of the disease is removed a cure must follow. 
If, for instance, the local morbid lesions of the nose are overcome, the 
patient should be freed from the hay fever; if the neurotic habit is over- 
come, the hay fever should be cured; and if the patient is removed from 
the influence of the pollen, or is rendered immune by serums or antitoxins, 
he should be cured. Many a patient has been treated and operated upon 
with a view to the total removal of the local morbid lesions, but the hay 
fever paroxysms continued from year to year without abatement. Many 
a hay fever sufferer has been persistently treated for neurosis, and 
the various dyscrasias causing it, without effect upon the hay fever; 
and many a patient has been sent year after year to the mountains or to 
the northern lakes without preventing the recurrence of the paroxysms 
the following year. On the contrary, a few patients have been cured 



SENSORY, VASOMOTOR, AND REFLEX NEUROSES 259 

permanently by recourse to one or more of the foregoing methods of 
treatment. The same is true of other methods; a few are cured, though 
many are not benefited at all. A remedy that is efficacious for one 
subject is totally ineffective when applied to another. 

Either the existing ideas concerning the etiology or our methods 
of diagnosis of the local morbid lesions are wrong — probably both. 
Nevertheless, we can only act upon present knowledge. We must, there- 
fore, continue to remove the local morbid lesions from the nose and 
accessory sinuses, for this is the most hopeful method of treatment, 
unless the patient is removed to a place where the pollen or other irritant 
peculiar to his case is absent; or we must administer a serum that is an 
antidote to the pollen in question. In the meantime our knowledge 
of the morbid processes in the nose and accessory sinuses is rapidly 
advancing, and it may be that we shall soon be able to cure this elusive 
and distressing disease. 

Treatment. — The treatment may be divided into five groups, namely : 
(a) The treatment of the dyscrasias; (b) the removal of the local morbid 
processes in the nose and the accessory sinuses; (c) the removal of the 
patient from the influence of the pollen or other emanations which act as 
the exciting cause of the disease; (d) the immunization of the patient; 
and (e) the relief of acute symptoms. 

Treatment of the Neuroses and Dyscrasias. — The treatment of the 
neuroses and dyscrasias due to modern civilization is a very difficult 
undertaking. We are in a domain of pathological entities the forms 
of which are shadowy and the definitions obscure. We are dealing with 
unknown quantities upon hypotheses not yet proved. Failure is the 
almost inevitable result. While all this is true, something may still be 
done to improve rheumatic and gouty diatheses and the ill-defined 
neurotic manifestations. The intestines and stomach can be flushed by 
lavage and by saline cathartics. The kidneys and skin can be made to 
eliminate more freely, and the hemoglobin of the blood can be raised so 
as to attract more oxygen. These and other processes may be stimulated 
or modified so that the neurotic state of the nervous system and the 
various constitutional disorders are in a degree improved. Indeed, the 
treatment should include some of these measures, although a cure may 
never be effected by them. According to Major Woodruff, excessive 
exposure to sunshine is a cause of neurasthenia, and this may in a 
measure account for the greater prevalence of hay fever in America. 

Treatment of the Local Morbid Lesions .—(a) The circumscribed sensi- 
tive areas should be cauterized with a flat electrode at white heat, 
without the use of a local anesthetic. The use of an anesthetic would 
make it impossible to find the sensitive areas, and, furthermore, the 
cauterization is superficial and lasts only a fraction of a second. The 
current should be turned on until the point of the electrode is almost 
instantly brought to a white heat. It should then be introduced cold 
into the nose, a sensitive area found with it, and the current turned 
on by pressing the button on the handle. The moment the white heat 
is seen in the nose the button should be released and the electrode 



260 THE NOSE AND ACCESSORY SINUSES 

removed. Another sensitive area should be found and cauterized in 
like manner. From four to five sensitive areas may be cauterized at a 
sitting. The treatment may be repeated in from five to seven days. 

(6) Nasal catarrh, if present, should be treated during the period 
of quiescence; that is, when the hyperesthetic rhinitis is not active. 
(See various forms of Chronic Rhinitis.) 

(c) Nasal polypi should be removed during the period of quiescence, 
although they may be removed during the acute paroxysms. (See 
Nasal Polypi or Myxoma.) 

(d) Deviations of the septum which cause any type of rhinitis, or which 
contribute to the causation of sinuitis, should be corrected during the 
period of quiescence, according to the methods described under Devia- 
tions of the Septum. 

(e) Sinuitis, either catarrhal or suppurative, should be treated during 
the period of quiescence, according to the methods described under the 
Inflammatory Diseases of the Nasal Accessory Sinuses. 

The late Dr. Schadle has reported that irrigation of the maxillary 
sinus results very favorably. At first a saponaceous substance is washed 
away, but the fluid finally comes away perfectly clear. Dr. Schadle 
believed that the ostium maxillare is so large that it admits the irritating 
substance which excite the paroxysmal attacks, and that when washed 
from the antrum the symptoms are relieved. I doubt this explanation, 
and am inclined to believe the relief is due to the lessened irritation of 
the nasal mucosa by the discharge from the antrum. 

I have known equally good results following the total exenteration of 
the ethmoidal labyrinth via the nose. One patient was compelled for 
three months each year to sleep in a sitting posture with her head upon 
a table. Since the radical removal of her ethmoidal sinuses the only 
manifestation of the old trouble is a mild asthma, which is present for 
short intervals at any season of the year. I have since performed a 
double Killian operation upon the frontal sinuses of this patient with 
complete success. This operation has apparently had no influence on 
the slight asthma. 

In view of my theory of the etiology of hay fever, in selected cases, 
being sinuitis, and of Dr. P. M. Farrington's successful treatment of 
such cases by autogenous vaccines, it is proper to suggest the autog- 
enous vaccine therapy in this disease. Inject 50,000,000 bacteria 
at the first treatment, gradually increasing the dose to 100,000,000 
at the third treatment. The injections should be made every third or 
fourth day. 

Protection of the Patient from the Pollen or Other Emanations which 
Excite the Acute Paroxysms. — (a) Small, soft sponges may be worn 
in the vestibules of the nose to filter the pollen and other irritating 
substances from the inspired air. They are sometimes effective, but, 
on the whole, are unsatisfactory. A moistened handkerchief may 
also be utilized for the same purpose by holding it close to the nasal 
openings. At best, these devices afford temporary relief, and cannot 
be depended upon throughout the paroxysmal period. 



SEXSORY, VASOMOTOR, AND REFLEX NEUROSES 261 

(b) The geographical treatment consists in the removal of the patient 
to a place where the exciting emanations are absent. Lake Superior 
or the Muskoka region in Canada and the Adirondack Mountains are 
favorite resorts for many patients in the United States and Canada. 
An extended ocean or lake trip is also a satisfactory method of escaping 
from the emanations of the irritating pollen, etc. 

While the geographical treatment is not always effective, it is nearly 
always so if protracted over the entire period of the acute exacerbations. 
Some patients may return before the expiration of this period without 
experiencing a recrudescence of the acute symptoms, although this is 
rarely so. Others are not relieved by a change of geographical location; 
at least, all cases are not relieved by a change to the same locality. Each 
patient must learn by experience the place best suited for him. On the 
other hand, he may find relief for a number of seasons in one locality, 
and upon returning the following year may experience but little or no 
relief. Under these circumstances he should try another locality. If, 
for instance, he has been going to the Lake Superior region or the 
Muskoka Lake region, he should be sent to a higher altitude, as the 
Adirondacks or the Rocky Mountains. 

Palliative Treatment. — Various local and internal remedies have been 
advocated, but none of them are of universal value. They may be 
tried in series in individual cases until one is found that gives relief. 

(a) The extract of the suprarenal gland is often successfully used. 
It should be prepared, according to Dr. H. L. Swain, by adding 10 to 20 
grains of the powdered gland to one-half dram of cold, sterile water. 
After stirring thoroughly, it should be filtered and a few drops of alcohol 
added to prevent early decomposition. Boric acid, cinnamon water, and 
camphor water may also be used to prevent decomposition. \Mien 
thus prepared it should be applied to the nasal mucous membrane with 
a spray tube, or with thin pledgets of cotton pasted over the surface of 
the mucous membrane. It is harmless, except in those occasional cases 
in which it excites irritation and sneezing. S. Solis Cohen has used it 
internally with success. 

(b) Insufflation of the powdered sulphate of quinine into the nose has 
been recommended. I have used it in a few cases with complete success, 
and in many others without result. When it is effective the nasal mucous 
membrane becomes dry and the turgescence disappears. The absorption 
of the drug causes tinnitus. In one case two insufflations of 5 grains 
each were followed by complete relief which lasted throughout the 
paroxysmal season. This case was a mild one, beginning the latter part 
of August. 

(c) Alkaline and oleaginous solutions may be sprayed into the nose, 
with temporary relief. In some cases a postnasal douche of boric acid 
solution is soothing. Oil with menthol in 0.5 per cent, solution, or with 
0.1 per cent, of formaldehyde, sometimes gives relief to the inflamed 
membrane. The formaldehyde burns for a few seconds and is followed 
by a grateful sense of relief. 

(d) The itching at the inner canthi of the eyes may be relieved by 
irrigating with boric acid or normal salt solution. 



262 THE NOSE AND ACCESSORY SINUSES 

(e) The rays of the 500 candle-power incandescent lamp (Fig. 100) 
applied for ten to twenty-five minutes over the face, with the eyes closed, 
at a distance of from twelve to eighteen inches, increase the speed of 
the arterial and venous currents. The passive congestion and edema are 
thereby reduced and the relief is considerable. (See Leukodescent Light 
and the Technique of Application.) The light should be applied from 
one to four times daily. In those cases in which its use is attended 
by marked relief a lamp may be installed in the patient's home. A lower 
power than 500-candle-power is not recommended, nor is a cluster of 50 
candle-power lamps as efficacious as a single 500-candle-power lamp. 
The therapeutic value of the light is chiefly determined by the candle- 
power of a single lamp, no matter how many are connected in a series 
or in a group. 

(f) Powdered diphtheria antitoxin has been used locally with gratifying 
results (Pierce). Numerous other local remedies have been recommended 
from time to time, but have proved of little value after more extensive 
trial. 

(g) Antilithemic remedies, as the salicylate of soda, have been ex- 
tensively used to counteract the uric acidemia with indifferent success 
except in occasional cases. 

Serum Treatment. — The serum treatment recently introduced by 
Dunbar, while not perfected, affords relief in some cases. Sir Felix 
Semon, Liebreich, and Lobe indorse Dunbar's serum treatment, with the 
proviso that all the conditions recommended by him be observed. The 
serum is prepared in liquid and powdered form, the powder being the 
more stable and reliable. The solution may be applied to the conjunctiva 
or the nasal mucous membrane. The object of the serum is to afford 
immediate relief and ultimately to establish immunity. The conditions 
attending its use are so complex that it is at present a rather unsatis- 
factory remedy. 

In my opinion, serum treatment will not solve the problem of the 
management of hay fever or its kindred types of hyperesthetic rhinitis. 
The predisposing factors are ignored in this method of treatment. There 
are conditions which render the mucous membrane of the nose suscep- 
tible to irritation by the toxin of pollen and other substances which 
excite hay fever. Heretofore we have regarded the neuroses and con- 
stitutional dyscrasias, the various obstructive lesions of the septum, and 
the catarrhal affections of the nasal mucous membrane as the predis- 
posing causes. The treatment applied in accordance with these ideas 
has generally been disappointing. In my opinion we must look beyond 
the nasal chambers to the accessory sinuses for the real conditions 
which predispose the mucous membrane of the nose to the irritation by 
the pollen of certain grasses, flowers, etc. The irritation caused by the 
more or less constant discharge from the sinuses is, I think, a rather 
common cause of hay fever. Schadle has called attention to the relief 
afforded by the irrigation of the maxillary sinuses. According to my 
observations the exenteration of the ethmoidal sinuses (including the 
removal of the middle turbinate) has apparently resulted in a cure 
extending over three years. The sinuitis may or may not be purulent. 



SENSORY, VASOMOTOR, AND REFLEX NEUROSES 263 

Indeed, the catarrhal type is often more irritating than the purulent as 
shown by the excoriations and fissures at the margin of the vestibules 
of the nose. 

In view of these facts I believe that the ultimate cure of hyperesthetic 
rhinitis and asthma will not be found in the serum treatment, but in the 
proper comprehension and treatment of catarrhal and suppurative 
sinuitis. This will include the obstructive lesions of the septum and the 
structures within the "vicious circle" of the nose. The neurotic element 
is often so marked in these cases that any method of treatment may fail. 

According to O. J. Stein the injection of a few drops of alcohol into 
the mucous membrane of the nose at the point where the sensitive 
branches of the sphenopalatine ganglion enter the nasal chambers (Fig. 2) 
controls the acute symptoms in hay fever subjects. Three to four injec- 
tions at intervals of a few days suffice to control the attack throughout 
the season. 

According to O. J. Stein, but two factors are necessary for the causa- 
tion of hay fever, namely: (a) An internal irritant, which affects the 
sensitive nerve filaments, and (b) an external irritant, as dust, cold, 
light, the pollen of certain plants, etc., which affects the fifth nerve 
supplying the nasal chambers. 

The internal irritant is the result of faulty metabolism, which causes 
what may be called the susceptibility of the individual, i. e., a disturbance 
of the normal functional equilibrium. 

The external irritant may be dust, pollen, a draught, light, cold, heat, 
pungent odors, the discharges from infected sinuses, etc. It need not 
enter the nose to produce irritation, as any area supplied by the fifth 
nerve may be the origin of the reflex symptoms. Hence a bright ray of 
light entering the eye may irritate the hyperesthetic ciliary nerve filaments 
and cause reflex symptoms in the nose, or a draught of air striking the 
side or back of the head may produce nasal reflex phenomena. 

Technique. — (a) First correct any disturbance of metabolism and 
nutrition that may be present. 

(6) Remove the local and external causative irritating factors, such 
as spurs and ridges of the septum, secretions from the sinuses and 
sensitive areas, and protect the patient from the particular pollen that 
poisons him, by instructing him to wear sponges in the vestibules of the 
nose, or by sending him to some place where this pollen is absent. If 
the eyes are the source of irritation, the patient should wear dark glasses. 

(c) Reduce or temporarily abolish the sensibility of the nasal portion 
of the fifth nerve. This may be accomplished in some measure by the 
administration of certain drugs, as morphine, the bromides, atropine, 
cocaine, etc. The action of these drugs is transient, and they may have 
deleterious effects, and are not recommended, but on the contrary their 
use for this purpose is condemned. 

Stein's Treatment. — Dr. Stein recommends that the nasal branches 
of the fifth nerve be desensitized by the injection of alcohol into the 
nasal chambers. The nerve enters through the most anterior perfora- 
tion in the cribriform plate (Fig. 203), and the needle should puncture 



264 



THE NOSE AND ACCESSORY SINUSES 



this point and be made to penetrate the nerve sheath. The method of 
procedure is as follows: 

(a) Apply a 10 per cent, solution of cocaine to the cribriform and 
spheno-ethmoidal region of the nasal chambers. 

(6) The straight needle, previously sterilized, is attracted to the glass 
syringe which contains the alcohol. It is then carefully inserted into the 
tissues just posterior to the nasal bone, i. e., the anterior extremity of the 
cribriform plate (Fig. 203, a). Five drops of alcohol are then injected 
and the needle is withdrawn. The other nostril is then similarly treated. 
The posterior group of nerves is seldom treated at the first sitting, because 
in the majority of cases Dr. Stein has found that the injection of alcohol 
into the anterior group will control the symptoms. If, however, after a few 
days no relief is experienced the posterior group of nerves may be given 
an injection. For this purpose a longer needle with a curved tip is used, 
as shown in Fig. 203, c. The posterior nerves may be reached by direct- 
ing the curved needle tip outward, upward, and slightly backward at the 
posterior extremity and lower border of the middle turbinate. After one 



Fig. 203 




c 



Stein's method of treating hay fever: a, the anterior point where the needle is inserted; (6) the 
hypodermic syringe filled with alcohol; (c) the posterior point where the needle is inserted. 

to four treatments, the patient should have relief through the hay fever 
season. No ill effects have occurred other than a slight hemorrhage, 
and pain and dizziness of short duration. This treatment does not pro- 
tect against the recurrence of the symptoms the following season. 

Killian has suggested and successfully practised the injection of 
cocaine into these nerves to produce anesthesia preliminary to intranasal 
operations. 

ACUTE CIRCUMSCRIBED EDEMA OF THE NOSE; CORYZA EDEMA- 
TOSA; ACUTE CIRCUMSCRIBED EDEMA 

This affection may involve both the pharynx and larynx in the same 
case. It is not an inflammatory affection, but is an edema of neurotic 



NASAL HYDRORRHEA; RHINAL HYDRORRHEA 265 

origin, and probably results from some disturbance of the digestive tract. 
It is quite like urticaria, though it involves the mucous membrane. It is 
usually associated with other symptoms or diseases, as hay fever, urticaria 
of the skin, headache, gastro-intestinal disturbances (as watery vomiting 
and colicky pains), and itching. In Matas' case a distinct periodicity 
was present, the edema recurring regularly between 11 and 12 a.m. 
daily. In this case the toxin was probably the malarial plasmodium. 

I reported a case in 1896 in which the angioneurotic edema came on 
during an attack of hay fever. Gastro-intestinal disturbance was also 
present. The edema involved the nose, soft palate, and hypopharynx. 
The mucous membrane was swollen, gray, and semitranslucent. The 
suffocative symptoms were severe, although at no time was there 
imminent danger from this source. 

Numerous punctures of the edematous membrane were made and 
cocaine applied, after which the edema gradually disappeared. Free 
saline catharsis should be induced. 



NASAL HYDRORRHEA; RHINAL HYDRORRHEA 

Nasal hydrorrhea is a symptom of some other nasal lesion rather 
than a disease, and is characterized by thick, viscid, and slightly opales- 
cent secretion more or less rich in mucin. The amount of discharge 
varies from a few ounces to a pint or more in twenty-four hours. Accord- 
ing to St. Clair Thompson, the secretion contains amorphous matter 
and mucous corpuscles. The secretion when tested with alcohol or 
acetic acid throws down a stringy precipitate like mucin. When the 
precipitate is boiled with dilute sulphuric acid, a sugar-like material is 
formed; this is probably due to the presence of mucin. The proteid is 
coagulated by heat; it does not reduce Fehling's solution. Peptones and 
proteoses are absent. The alcohol extract of the secretions contains no 
reducing substance. The secretion may be distinguished from normal 
cerebrospinal fluid by the presence of mucin and the absence of a 
reducing substance. 

Symptoms. — The clinical picture of nasal hydrorrhea shades off 
in one direction into cases of what are generally called hay fever, with 
symptoms of intense local irritation, while in the other direction it 
may consist of a passive and almost painless watery discharge from the 
nose. It is apparently a disease of adult life, which affects males and 
females equally. Although it may be more marked on one side of the 
nose than on the other, the flow usually comes from both nostrils. 
When handkerchiefs are soaked with it they generally become stiff when 
dry. In cerebrospinal rhinorrhea, on the other hand, the discharge is so 
watery that handkerchiefs dry quite soft; and in this affection the dis- 
charge is limited entirely to one nostril, unless there happens to be 
some obstruction on the affected side, when it may make its way to the 
opposite nasal fossa. When the fluid is of arachnoid origin, headache or 
other mental symptoms are frequent, but are relieved by the discharge. 



266 THE NOSE AND ACCESSORY SINUSES 

The disease is not accompanied by lacrymation or suffusion of the con- 
junctiva, and photophobia, and it may occasionally give rise to sneezing, 
especially in the morning. 

In nasal hydrorrhea the feeling of malaise begins with the discharge 
and only stops with its cessation. It is frequently ushered in with sneez- 
ing, photophobia, and lacrymation. It rarely continues during sleep, 
while cerebrospinal rhinorrhea continues day and night. It is very erratic 
in its onset and in its intermissions, and is very dependent on external 
influences and on conditions of health. Moritz Schmidt states that 
some cases have been observed which were dependent on ulcer of the 
stomach or biliary lithiasis. He defines the disease as a vasomotor rhinitis. 
McBride recognizes the diversity of the conditions of which nasal hydror- 
rhea may be but a symptom. I have seen cases in which the reactions 
given by St. Clair Thompson were present, thus differentiating the 
condition from cerebrospinal rhinorrhea. 

Treatment. — The treatment should be addressed to the morbid 
nasal lesions, such as are found in hay fever or other forms of hyper- 
esthetic rhinitis, or to any other pathological condition present in the 
nose and accessory sinuses. 



CEREBROSPINAL RHINORRHEA 

St. Clair Thompson, in 1899, made a notable contribution to rhino- 
logical literaturewhen he described for the first time the escape of cerebro- 
spinal fluid from the nose. Such cases had been previously regarded as 
nasal hydrorrhea. Thompson's analysis of his and other cases, recorded 
in the literature under various names, made the differential diagnosis 
between cerebrospinal rhinorrhea and nasal hydrorrhea quite clear. 
The subarachnoid fluid may, under conditions not yet clearly demon- 
strated, escape from the cranial cavity through the nose without apparent 
harm to the patient. The fluid is clear and watery in contrast to the 
slightly opalescent and viscid fluid of nasal hydrorrhea. The drip- 
ping is constant and is free from taste, sediment, odor, albumin, and 
mucin. It reduces Fehling's solution. 

Etiology. — The etiology is as yet but little understood, although 
Thompson is inclined to believe that there is some pathological change 
in the contents of the skull leading to increased intracranial pressure. 
In 17 out of 21 cases recorded there were cerebral symptoms, and 8 
showed retinal changes. The following table prepared by St. Clair 
Thompson gives the essential tests for cerebrospinal fluid: 

1. The fluid is perfectly transparent like water, and contains no 
sediment. 

2. It is faintly alkaline in reaction, and either tasteless or slightly 
salt. 

3. The specific gravity is between 1005 and 1010. 

4. It is not viscid, and gives no precipitate (mucin) on adding acetic 
acid. 



EPILEPSY OF NASAL ORIGIN 267 

5. On boiling there is not more than a trace of coagulum of serum 
globulin and serum albumin. 

6. Cold nitric acid gives a precipitate which disappears on heating, 
and separates again on cooling. 

7. Saturation with magnesium sulphate should give a precipitate. 
Saturation with sodium chloride should also produce a precipitate. 
Ammonium sulphate should be tried if the above salts fail. 

8. The liquid should give a pink or rosebud color with a trace of 
copper sulphate and excess of caustic potash. 

9. When boiled with Fehling's solution there should be a reduction 
of the copper (due to pyrocatechin or some similar body). 

10. The reducing substance may be obtained by evaporating to 
dryness an alcoholic extract of the fluid. It is then found in the form 
of needle-like crystals. 

11. The aqueous solution of this residue does not ferment with yeast. 
If applied to suspected cases, these tests will in future avoid any 

question as to the true nature of cerebrospinal fluid when it escapes 
from the nose. 

Treatment. — The successful treatment of cerebrospinal rhinorrhea is 
obviously almost impossible. Whatever may be done, extreme care 
should be exercised to avoid infection of the nose, which might be com- 
municated to the meninges or to the cerebrospinal fluid of the brain and 
spinal cord. 

ASTHMA 

Asthma may or may not be of nasal origin. The bulbar nuclei of the 
fifth nerve has an anatomical connection with the vagus, hence it is 
possible for an irritation in the nose to excite reflex phenomena in the 
lower respiratory tract. The most common cause of asthma of nasal 
origin is ethmoiditis accompanied by nasal polypi. In other cases 
hypertrophy, hyperplasia, and other morbid lesions appear to cause it. 
On the other hand, these conditions are often present without exciting 
asthma. 

Treatment. — The treatment of asthma of nasal origin consists in the 
correction of the nasal morbid lesions, especially ethmoiditis, polypi, or 
hypertrophy of the turbinated bodies. (See Ethmoid Operations.) 

A useful test as to the curability of the case is to apply a solution of 
cocaine to the mucous membrane of the nose, and if the asthma is greatly 
relieved or altogether checked, it is probable that the removal of the 
morbid lesions will result in a cure, though this cannot be positively 
promised, nor can it be stated how long the relief will continue. 



EPILEPSY OF NASAL ORIGIN 

Epilepsy of nasal origin has been reported by various authors. W atson 
Williams refers to a case which was brought on by cauterizing the nose 



268 THE NOSE AND ACCESSORY SINUSES 

for nasal polypi. He also cites two cases reported by Baron: one 
case had nasal polypi, the removal of which was followed by marked 
alleviation of the epileptic seizures; the other case was a young unmar- 
ried woman who had had epileptic fits at her menstrual periods from 
the time menstruation began. Her inferior turbinated bodies were 
greatly hypertrophied, and she was always troubled with nasal stenosis 
during the menstrual periods, and it was at these times only that the 
fits occurred. Removal of the hypertrophied tissue was followed by a 
cessation of the fits for seven or eight months, and when they began 
again the turbinal hypertrophy was found to have returned. 

I have a patient who has sarcoma of the nose, upon which I operated 
in April, 1903, and who has had repeated epileptic fits since the operation. 
Following each fit I have found a sequestrum of bone in the ethmoid 
region near the cribriform plate, after the removal of which the fits 
did not return for several weeks or a few months. 

Nasal Tachycardia. — Watson Williams in his treatise on Diseases 
of the Upper Respiratory Tract cites the experiments of Gruber and 
the reports of several cases as follows : 

Of the 43 subjects tested by Gruber, 13 with normal noses and 30 
with nasal disease, the irritation of the nasal mucosa was negative. 
Watson Williams has never seen a case of reflex effect on the heart 
from nasal disease, though Spencer Watson reports one apparently 
due to polypi. Charsley observed, after cauterization of the inferior 
turbinate, temporary exophthalmos with tachycardia, the pulse ranging 
as high as 110 per minute, lasting for a period of three months. B. 
Frankel and Hack report cases simulating Graves' disease, with goitre 
and tachycardia, which disappeared after curing the existing nasal 
disease. 



CHAPTEE XIII 

NEOPLASMS OF THE NOSE 
MYXOMA, OR NASAL POLYPUS; HYPERPLASTIC RHINITIS 

Myxoma, or nasal polypus, is usually a pedunculated tumor of 
hyperplastic tissue, which most often grows from the middle turbinated 
body, the uncinate process of the ethmoid bone, or the ethmoidal 
cells, though it is not infrequently present in the maxillary frontal and 
sphenoidal sinuses. It is usually significant of a preexisting catarrhal or 
suppurative inflammation of the sinuses, and is classified by Uffenorde 
as hyperplastic rhinitis (Skilleren). Some believe the tumor is primary 
and the inflammation of the sinuses secondary. Such a belief probably 
results from an indefinite conception of the symptoms of catarrhal 
sinuitis. Fortunately, catarrhal inflammation of the sinuses is now well 
understood, and I believe that clinical experience will show that the 
inflammation exists prior to the formation of the myxomatous tumors. 

Etiology. — While it has not been definitely proved that nasal polypi 
are directly due to sinuitis, they nevertheless often appear to be secondary 
to such an inflammation. If the cases are carefully studied, it will often 
be found that the patients complain of a vague frontal headache, pressure 
between the eyes, dizziness, especially upon stooping forward, irritability 
of the eyes upon prolonged reading, or difficulty in securing a proper 
refraction of the eyes. Some or all of these and other symptoms are 
present in catarrhal as well as in suppurative sinuitis. It is claimed that 
repeated attacks of coryza may cause polypi. This is practically equiva- 
lent to saying that they are due to sinuitis, as the distressing symptoms of 
coryza are usually due to the associated inflammation of the accessory 
sinuses. Clinically we know that polypi are often associated with sup- 
purative sinuitis and with caries of the bone in the immediate neighbor- 
hood of the tumors. Some writers state that polypi are found in the less 
obstructed nasal cavity, and use this as an argument against the previous 
existence of sinuitis. I believe that a careful examination of the nose 
will show that the polypi are usually present on the side of the nose in 
which there is the greatest obstruction in the region of the middle tur- 
binated body, or "vicious circle" of the nose. A casual examination of 
these cases often shows a concavity on the side of the polypus, but the 
concavity is in the lower portion of the nasal chamber, while there is a 
convexity high up on the same side. It is easy to understand how 
the examination might show an open nostril on one side in this instance, 
if the lower portion of the nose only were taken into consideration. 
If, however, the upper portion is considered, the obstructive lesion is 
readily discovered on the side where polypi are present. 

(269) 



270 THE NOSE AND ACCESSORY SINUSES 

One of the most frequent causes of nasal polypi is a preexisting inflam- 
mation of the membrane of the nasal sinuses and of the nasal mucosa in 
the region of the cell openings. The irritation and pressure give rise 
to a passive congestion and a proliferation of cells. A serous or edema- 
tous infiltration is a later manifestation. The connective-tissue cells 
subsequently become filled with the serum, thus leading to a hydropic 
degenerative change in some cells, and a myxomatous or gelatinous 
change in others (D. Braden Kyle). 

The tissue thus degenerated becomes pendulous and in most instances 
pedunculated. Such a tumor is known as a polypus. 

Hyperplasia of the nasal mucous membrane, due to other causes, may 
develop into nasal polypi. If, for instance, a foreign body is lodged in the 
nasal chamber for a long time, or any other continued source of irritation 
is present, it may result in nasal polypi. Some writers claim that the 
suction of the inspiratory current of air produces the tumors. D. Braden 
Kyle has pointed out that the ingoing current of air exerts as much 
pressure as it does suction. As a matter of fact, the presence or absence 
of suction depends largely upon the location of the obstructive lesion of 
the septum in relation to the polypi. If the polypus is posterior to the 
obstructive lesion, it is subject to suction from the rarefied or negative 
air pressure posterior to the obstruction. If there is no anterior nasal 
obstruction, the polypi are subjected to pressure rather than to suction. 
Suction may have something to do with the formation of polypi in 
some cases, but it is not probable that it is often if ever the sole 
cause. 

Pathology. — While polypi are usually called myxomata, they are, 
as a rule, fibro myxomata. Pure myxoma is rare, and when found con- 
sists of an epithelium-covered connective-tissue sac, which contains a 
mucoid fluid, some bipolar spindle cells, and a fine network of con- 
nective tissue. The fibromyxoma, the usual type, is much richer in 
connective tissue, and less so in mucoid fluid. The tumors are supplied 
with bloodvessels and nerve filaments, which do not penetrate the sub- 
stance of the tumor, but are limited to the mucous membrane covering 
it. They contain plasma cells, which stain with polydrome, methylene 
blue, and eosin. Robert Levy reports a case of multiple cystic polypus 
richly supplied with bloodvessels, as shown in Fig. 205. 

Symptoms. — The symptoms of nasal polypi are often complex on 
account of the nasal obstruction (middle turbinal region) and the asso- 
ciated inflammation of the nose and sinuses, which usually co-exist. 

The symptoms caused by the polypi are largely dependent upon their 
location, size, and the amount of obstruction produced. If pedunculated, 
and hanging into the lower portion of the nose, they give rise to the 
sensation of a movable foreign body. The patient can sniff and blow 
them back and forth in the nose at will. If sessile, they cannot be 
thus moved, but cause a feeling of tightness or of fulness across the 
bridge of the nose. The voice has the nasal twang in proportion to the 
obstruction produced. The voice is often muffled, owing to the almost 
total loss of nasal resonance. 



MYXOMA, OR NASAL POLYPUS 



271 



Upon examination a grayish semitranslucent tumor is seen hanging 
in the middle meatus of the nose. If pedunculated, it may move with 
the inspiratory and expiratory currents of air. Pressure with a probe 
shows a soft and yielding mass freely movable in the nasal chamber. 
There may be single or multiple tumors, but the latter are the more 
frequent. H. YV. Loeb reported a case from which he removed 308 polypi 
at one sitting. They varied in size from that of a pinhead to such pro- 
portions as to protrude from the nose. 



Fig. 204 




The apparently open nostril, only open in its 
inferior portion. The obstruction in the upper 
portion interfering with drainage and ventila- 
tion of the sinuses, hence it gives rise to sinuitis, 
or hyperplastic ethmoiditis and later to polypi. 
Nasal passage obstructed in its lower portion. 
Open in the upper portion, hence drainage and 
ventilation of the sinuses are good; sinuitis 
and polypi absent. Polypus likely to form on 
the apparently open side, but in reality on the 
side where there is an obstruction in upper or 
sinus portion of the nose. 



Fig. 205 




A polypus of the cyst adenoma type removed 
from the nose: 4 cm. long, 2.5 cm. wide, 1.25 cm. 
thick, weight 8 grams, color pinkish white, solid 
and elastic. The section shows numerous cavi- 
ties filled with colloid and caseous material. 
Some of the cysts are lined with ciliated epi- 
thelium; others have a degenerated columnar 
cubical or flattened epithelium, and in some 
the epithelium is entirely lost. Some areas are 
infiltrated with inflammatory round cells: a, 
bloodvessel; b, cyst. (Robert Levy's specimen.) 



Various reflex symptoms, as cough and asthma, may be caused by 
polypi. I have seen a case in which the cough and asthma were so 
persistent as to compel the patient to sleep every night for three months 
at a time with the head on a table. This and other similar cases were 
relieved by the removal of the polypi and the total exenteration of the 
ethmoidal cells. External signs of nasal polypi are not always present, 
excepting the inclination to keep the lips parted, to supplement the 
nasal breathing. In rare cases the tumors are of such aggregate 
magnitude as to broaden the bridge of the nose. 

The sense of smell may be impaired or lost, owing to the closure of 
the olfactory fissure. The pharynx may be dry on account of the loss 
of the nasal respiratory functions, or from the thick, tenacious mucopus 
which is discharged into it. 



272 THE NOSE AND ACCESSORY SINUSES 

Caries and necrosis of the bone of the middle turbinal and of the eth- 
moidal cells may be found in some cases by the use of a heavy blunt- 
pointed probe. A small probe should not be used, because it might 
readily pass through the degenerated mucosa and lead to a mistaken 
conclusion as to the condition present. The probe should be gently 
passed over the mucous membrane of the middle turbinal, the ethmoid 
space above, and along the lip of the hiatus semilunaris (uncinate pro- 
cess), as these are the most frequent sites of nasal polypi. 

The symptoms of the associated disease of the sinuses are headache, 
dizziness, especially upon stooping or sudden jarring, irritability of the 
eyes upon prolonged reading, or occasionally unilateral blindness. 
(See Diseases of the Sinuses.) 

Prognosis. — The prognosis of nasal polypi is good if they are removed, 
and the preexisting disease of the nose and sinuses which caused them is 
also remedied. In those cases in which the cause is a slight nasal inflam- 
mation the removal of the polypi followed by cauterization of their points 
of attachment will effect a cure. If the polypi are removed and the 
cauterization is neglected they are likely to recur. In those cases which are 
due to hyperplastic rhinitis or suppurative inflammation of the sinuses, 
it may be necessary not only to remove the polypi, but to exenterate 
the ethmoidal sinuses also. If caries of the bone is present, the operative 
procedure should include it as well as the polypi. 

Treatment. — In view of the tendency of the polypi to recur, the treat- 
ment is not as simple as is ordinarily supposed. The average practitioner 
regards his duty as being performed when he removes the growth, or 
groAvths, and establishes a fair degree of nasal respiration. The aim 
should be, however, to not only remove the growth, but to remove the 
tissue from which it springs, and to remove the disease process (sinuitis), 
which is often the cause. Whether or not bony necrosis is always present, 
clinical experience teaches us that polypi are much less likely to return if 
the ethmoidal cells from which they often spring is removed. The use 
of the galvanocautery or fused chromic acid upon the stump of a solitary 
polypus effectually prevents its recurrence. 

The surgeon should ascertain as nearly as possible the points from 
which the polypi spring, so that he may determine the difficulties likely 
to be encountered in the operation, and formulate a correct prognosis 
if the operation is refused by the patient. 

Surgical Classification. — I. If polypi spring from the free border of the 
middle turbinated body their removal and after-treatment are compara- 
tively simple. In this location it is not difficult to engage the snare around 
the growths in such a way as to include also a portion of the middle 
turbinate from which they spring, or the turbinal tissue may be removed 
with Holmes' scissors. Thus in a single operation it is sometimes 
possible to eradicate both the growths and their points of attachment. 

II. If they have their origin above the middle turbinated body there 
is a strong probability that they come from the posterior ethmoidal 
cells. Here the treatment is much more complicated. It may become 
necessary to remove all, or a large part, of the middle turbinated body, 



MYXOMA, OR NASAL POLYPUS 273 

and to exenterate the ethmoidal cells. After this is done, the case may 
require attention for several weeks. 

III. When they have their origin in and around the hiatus semilunaris, 
either the maxillary, anterior ethmoidal, or the frontal sinus may be 
the seat of infection, and it may be necessary to perform a radical 
operation upon the affected sinus to effect a cure. 

IV. In other cases they spring from the anterior ethmoidal cells, in 
which case these cells and the frontal sinus may be seriously involved. 

It is evident, therefore, that the simple removal of the polypi, or myxo- 
matous growths, does not constitute the whole duty of the attending 
surgeon. Such treatment is usually only palliative and temporary. 
The presence of the polypi should be regarded as an indication that 
hyperplasia of the mucous membrane and bone and sinuitis are present. 
The principles of treatment for inflammation of the middle ear apply 
with equal force here. They are, briefly, (1) to establish free drainage; 
(2) to remove the morbid material; and (3) to maintain asepsis of the 
parts while healing is in progress. 

Operative Technique. — I. Polypi springing from the free border of 
the middle turbinated body are perhaps the most easily and successfully 
treated of the types enumerated above. They are accessible and are 
attended with less involvement of the deeper tissues than those which are 
in either of the other locations. The method of procedure is as follows : 

(a) Wash the nasal cavity with a warm antiseptic spray and apply 
adrenalin and a 4 per cent, solution of cocaine. This is most effectively 
applied on a thin pledget of cotton saturated with the solution and intro- 
duced with an applicator and adjusted over the operative field. The 
pledget should be left in position for about seven minutes. 

(b) Carefully inspect the polypus by the aid of reflected light, and 
determine as nearly as possible its point of attachment. Having deter- 
mined that it springs from the free border of the middle turbinated body, 
the next step is to examine for evidences of other diseased processes. 

(c) With a large blunt probe the point of attachment and the neighbor- 
ing parts should be examined for bare, rough bone. If a small probe is 
used, it may penetrate the unbroken tissue and thus come into contact 
with bony tissue. It is quite important, therefore, that a large one be 
used. It is not always possible to detect denuded bone, but if the examina- 
tion is made in every case it may be found where it is not otherwise 
suspected. 

(d) The wire loop of the snare should now be introduced, so as to 
encircle the pendent tumor. It should be held so that both sides of 
it are against the septum, the lower portion of the loop being on a level 
with or lower than the inferior portion of the polypus. It should then 
be turned so that its inferior part passes outward under the polypus, 
and then in an upward direction until the polypus is encircled. The 
procedure is often facilitated if the loop is also moved slightly in a 
forward and backward direction while engaging the polypus. 

(e) Care should be exercised to carry the loop so as to include the 
point of attachment and a portion of the middle turbinated body if 

18 



274 



THE NOSE AND ACCESSORY SINUSES 



possible. If the growth is on the anterior portion of the turbinate it 
is usually easy to include the anterior third of it. The loop passes 
backward, under, and on either side of the turbinate, while the cannula 
(Fig. 206) is firmly placed in the notch formed by the anterior attachment 
of the turbinate to the anterior wall of the nose. 

(/) Firm pressure of die cannula into the notch being maintained, 
the loop is tightened until the tissues are engaged. It is still further 
tightened until the anterior portion of the turbinate, to which the growth 
is attached, is severed. 

(g) With a blunt probe the wounded surface is examined for evidences 
of carious or necrotic bone. 

(h) If softened or necrotic bone is found it should be removed by 
curettement. 

(i) If none of the middle turbinated body is removed the fibrous base 
of the polypus should be cauterized at the next sitting three or four days 
later. 

Fig. 206 




Removing a polypus and anterior end of the middle turbinate with a snare. 



(y) The after-treatment should consist of the use of warm antiseptic 
douches or sprays and the insufflation of bismuth-iodine powder. If the 
douche is used, the Birmingham nasal douche is preferable to any of the 
pressure or fountain douches, as they are likely to force the solution into 
the middle ear, or the region may be packed with cotton saturated with 
a 10 per cent, solution of ichthyol. 

II. When the polypi have their attachment above the middle turbinated 
body they usually spring from the posterior ethmoidal cells, and the treat- 
ment is correspondingly more difficult. One may be able to remove a 
portion of the growths, but it is difficult to reach their points of attach- 
ment. It therefore becomes necessary to remove the anterior half or 
all of the turbinated body. This is not objectionable, as the ethmoid 
cells contained therein and those in the body of the ethmoid bone are 
probably more or less filled with budding polypi. In cases of this class 



MYXOMA, OR NASAL POLYPUS 275 

my method of procedure is the same as for the removal of the ethmoid 
cells and middle turbinate en masse. 

III. If the polypi spring from the hiatus semilunaris or infundibulum 
it may become necessary to open the maxillary antrum, which may also 
be the seat of similar growths. 

These should be removed with the cold-wire snare and their bases 
cauterized. If upon further observation the antrum is found to be 
affected, the Caldwell-Luc or Denker operation should be performed. 

IV. When the polypi are attached to the border of the hiatus semi- 
lunaris, mouth of the infundibulum, there is probably an involvement 
of the anterior ethmoidal and the frontal sinuses. The treatment is 
much like that described in I, in so far as the removal of the polypi is 
concerned. Subsequently it may become necessary to remove the anterior 
half of the middle turbinated body. 

After this is done the diseased area is exposed to further examination, 
and, if necessary, to more extensive operation by curettement. In other 
words, the obstructions within the "vicious circle" should be obliterated. 

No arbitrary rules can be laid down in a text-book for the guidance 
of the surgeon. He must study the facts in each case, and arrive at a 
conclusion as to the best course to pursue. The foregoing operations 
are sometimes advisable if it is hoped to effect a permanent cure of 
nasal polypi. These operations are usually only described in connection 
with the subject of empyema of the nasal accessory sinuses. I have 
described them in connection with polypi in order to emphasize the 
significance and importance of these growths, as pointing to conditions 
much more important than the polypi themselves. While in some cases 
it may not be shown that the polypi have much significance, nevertheless, 
in my experience, the more nearly I have treated polypi as though necrosis 
and suppuration were associated with them, the more satisfactory have 
been my results. 

For timid patients non-surgical treatment may be recommended, as 
the injection of a saturated solution of the sulphate of zinc, or a solu- 
tion of tannic acid into the substance of the polypi. I have occasionally 
used tannic acid with satisfactory results. A few minims should be 
injected with a hypodermic syringe into the body of the tumor. Within 
two or three days it shrinks and sloughs away. In the aged or the infirm 
it is usually inadvisable to recommend measures more radical than 
the simple removal of the polypi, as the danger from shock and acute 
infection is greater in these subjects. 

Papilloma. — Papilloma of the nose is rare, but when it occurs it appears 
as a corrugated red mass growing either from the inner or inferior sur- 
face of the inferior turbinated T)ody, the septum, or the posterior end 
of the inferior turbinated body. The subjective symptoms are those 
of a partial nasal stenosis; the patient often consults the physician only 
on account of nasal "catarrh." 

Treatment. — The treatment consists in the complete removal of the 
growth with a snare or nasal scissors. The surrounding tissue should 
be anesthetized by the local application of a 5 to 10 per cent, solution 



276 



THE NOSE AND ACCESSORY SINUSES 



Fig. 207 



of cocaine, after which the tumor is excised. After the bleeding has 
ceased the wounded surface should be mopped dry and cauterized with 
the galvanocautery. This is done to prevent a recurrence of the growth. 
When papilloma recurs in a patient forty or more years of age, the 
possibility of carcinoma should be suspected. 

Fibroma. — Fibroma of the nose is characterized by the presence of a 
dense fibrous growth containing^ bloodvessels and no mucous glands, 
with slowly increasing nasal obstruction. The growths vary in size, are 
smooth and pale pink in color. They are firm to the touch or probe 
pressure, though not as dense as bone or cartilage. They may be sessile 
or pedunculated (Fig. 207). If pedunculated, 
they are movable like a polypus, though their 
consistency is quite different. 

They are usually attached to the septum, 
the floor of the nose, or to the turbinated 
bodies. They sometimes have multiple sec- 
ondary attachments, owing to the inflamma- 
tory reaction excited by their presence. 

Treatment. — The treatment consists in their 
complete removal, with a snare or cutting 
forceps. In those cases in which the tumor 
is pedunculated and comparatively small, the 
removal with the cold- wire snare or the author's 
turbinotome is the easiest and best method 




to pursue. 

When the growth is sessile and large it 
may be removed piecemeal with cutting for- 
ceps, or at least so much of it that the snare 
can be passed over the remainder. This pro- 
cedure may be done under cocaine anesthesia. 
When the growth is so large that it invades 
the surrounding structures of the nose, and 
extensive adhesions are present, it may become 
Fibromyxoma removed from necessary to resort to a temporary resection 
£3£rS* triX ^ the superior maxilla to eradicate it. 
a. g. wippem.) The operation as given in Surgical Tech- 

nique, by Drs. von Esmarch and E. Kowalzig, 
is as follows: Osteoplastic, or temporary, resection of the upper jaw 
(von Langenbeck, 1861) is performed for the removal of non-malignant 
fibrous or cavernous tumors which originate from the base of the skull, 
fill the nasal part of the pharynx (nasopharyngeal space), and force them- 
selves into the maxillary sinus, or through the sphenomaxillary fossa into 
the temporal fossa (retromaxillary tumors). 

By reflecting a portion of the upper jaw upward, which has been 
sawn through, but which remains in connection with the soft parts, 
the tumor is completely exposed, so that it can be cut off from the 
base of the skull with a knife or scissors; this portion of the upper jaw 
is then replaced and the skin is sutured over it. 



MYXOMA, OR NASAL POLYPUS 



277 



Von Langenbeck proceeds as follows: 1. An external incision is made 
down to the bone in the form of a curve from the external angle of the 
nostril to the middle of the zygomatic arch (Fig. 208). 

2. The insertion of the masseter muscle is separated from the lower 
margin of the malar bone portion of the buccal fascia. 

3. After the lower jaw has been pressed downward by a gag inserted 
at the angle of the mouth on the healthy side, the right index finger is 
forced into the sphenomaxillary fossa between the tumor and the upper 
jaw and then through the distended sphenopalatine foramen as far as the 
nares; an elevator is carried along the finger, and on it a fine metacarpal 
saw is introduced into the pharynx. The left index finger, introduced 
from the mouth into the pharynx, catches the point of the saw. 



Fig. 208 



Fig. 209 




The incision for the temporary resection of the 
superior maxilla. 




Von Langenbeck's operation for the tem- 
porary excision of the superior maxilla: a, b 
(Fig. 208), the external skin incision; e, the 
zygomatic arch is first sawn through from 
within outward; d, next, the frontal process of 
the malar bone is severed with a metacarpal 
saw as far as and into the inferior orbital fissure, 
the orbital plate of the inferior maxilla as far 
as the lacrymal bone closely below the lacrymal 
fossa, and, finally, the middle of the nasal pro- 
cess of the superior maxilla as far as the nasal 
bones are divided. The contents of the lacrymal 
canal should be carefully guarded from injury; 
6, horizontal division, with a saw, of the superior 
maxilla above the alveolar process as far as 
and into the pyriform aperture. 



4. Horizontal division is obtained by sawing the upper jaw above the 
alveolar process as far as and into the pyriform aperture (Fig. 209, 6). In 
operations on the right upper jaw, the left index finger is forced into the 
maxillary fossa, and the operator saws toward it from the nasal passage. 

5. Make the external incision down to the bone in the form of a curve 
from the root of the nose along the lower orbital margin, meeting the 
first skin incision at the zygomatic arch (Fig. 208). 

6. After the external lower angle of the orbit and the angle between 
the temporal and the frontal process of the malar bone have been freed 
from the soft parts the zygomatic arch is sawn through in the middle 
from within outward; next, the frontal process of the malar bone as far 



278 THE NOSE AND ACCESSORY SINUSES 

as and into the inferior orbital fissure, the orbital plate of the upper jaw 
as far as the lacrymal bone closely below the lacrymal fossa, and, finally, 
the middle of the nasal process of the upper jaw as far as the nasal 
bone divided with a metacarpal saw. The organs which constitute the 
lacrymal duct should be protected. 

7. By means of an elevator inserted under the malar bone the excised 
piece of the upper jaw is lifted up toward the median line, like the lid 
of a box. The sutural connection between the nasal bone and the upper 
jaw, in most cases, breaks during this maneuver. 

8. With a broad elevator the tumor, now laid bare, is lifted out of the 
sphenomaxillary fossa, and the base is detached from the under surface 
of the skull with a knife, scissors, or thermocautery. Finally, the resected 
portion of the upper jaw is replaced in its former position and the skin 
is closed by sutures. 

Adenoma. — Adenoma bleeds so readily upon examination with a 
probe that sarcoma is at once suggested. A microscopic examination, 
however, reveals the true character of the growth. This type of tumor 
grows from the septum or the ethmoidal region and produces rapidly 
increasing nasal stenosis. Adenoma, like polypi and papillomata, has 
a strong tendency to recur unless completely removed. It consists of a 
simple hyperplasia of gland structure having its type in the acinous or 
tubular glands. It also has a tendency to maligant degeneration. 

Treatment. — The treatment should consist in the total removal of the 
tumor. In order to insure this, its base should be cauterized or curetted. 
The bleeding which attends the removal of adenomata is considerable, 
but may be readily controlled by a nasal tampon of bismuth gauze. 

Lymphoma. — Lymphoma of the nose is characterized by a smooth 
mass, pinkish red in color, and less dense in consistency than fibroma. 
It is not common and a microscopic examination is necessary for a positive 
diagnosis. The treatment is the same as for polypus and fibroma. 

Angioma. — Angioma of the nose is rare (Harry Kahn), and consists 
of a distention of existing bloodvessels rather than of new-formed ones. 
According to D. Braden Kyle, the distention is due to changes in the 
walls of the bloodvessel from deficient nutrition rather than to mere 
congestion. 

Symptoms. — The symptoms are those of more or less nasal obstruction, 
epistaxis, and a reducible and pulsating tumor. The nasal obstruction 
is proportionate to the size of the growth. Pressure upon the growth 
materially reduces its size. The pulsation is greater when the tumor 
is attached to a large artery than if it is attached to a vein, when the 
pulsation is much less and the color is blue, whereas if it is connected 
with both vein and artery the color will be a dark red. 

Treatment. — The treatment consists in strangulation at the base of 
the tumor. The object of the strangulation is to cause closure of the 
bloodvessels which supply the tumor. If the strangulation is performed 
too quickly the vessels will not close and hemorrhage from their severed 
ends results; by gradually tightening the wire loop the vessels close and 
bleeding does not follow. 



MYXOMA, OR NASAL POLYPUS 279 

The galvanoeautery loop is also adapted to the removal of these 
growths, when easily accessible and pedunculated, as it sears over the 
ends of the vessels and prevents subsequent hemorrhage. When the 
growth is sessile, silk ligatures may be passed through it and tied, thus 
strangulating a portion with each ligature. Cocaine anesthesia by 
injection is all that is necessary for either of these procedures. 

Osteoma. — Osteoma 1 of the nose and the accessory sinuses is rare. 
It may occur in any of the accessory sinuses, but is more common in the 
frontal. It may invade the nasal and orbital cavities when growing 
from the sinuses. It sometimes springs from the inferior turbinated 
bone and occludes the nasal chambers. Cases have been reported 
in which the tumor had its origin in the nasal process of the superior 
maxilla. 

Pathology. — Osteoma is usually composed of dense, compact, can- 
cellous, horny tissue on a congenital or postnatal matrix of osteoclasts, 
and usually has its growth from the periosteum, though it may grow 
from the medullary portion of the bone. Some osteomata are soft and 
spongy, with a dense capsule of bone, while others are dense throughout 
their substance. The spongy type occurs most frequently. They are 
in some instances pedunculated, the pedicle being composed of either 
spongy bone or soft connective tissue and mucous membrane. They 
vary from the size of a small walnut to that of a goose egg. 

Symptoms. — As the nasal chambers are usually invaded, nasal obstruc- 
tion is a prominent symptom. The growth of the tumor externally 
produces more or less marked deformity, and in some instances the 
resemblance to horns is so great that the cases are referred to as " horned 
men." In some instances they present the " frog-face" type of counte- 
nance, especially when both sides of the nose are involved in the region of 
the infra-orbital ridge, as in O. J. Stein's case. Palpation of the tumor, 
whether intranasal or extranasal, yields a sense of bony hardness. The 
lacrymal duct may be occluded. The mucous membrane covering the 
tumor is usually pale, thin, and not eroded. Transillumination of the 
maxillary sinus may show obstruction to the rays of light. If constant 
mouth breathing is present it gives rise to epipharyngeal catarrh. In 
Stein's case there was inability to rotate the left eye inward. There 
was external divergence of two lines, the pupil was widely dilated and 
fixed, and did not respond to either light or accommodation. The fundus 
was normal. 

Diagnosis. — The diagnosis is largely based upon the microscopic 
examination of the tissue. 

Treatment. — In cases of syphilitic origin the iodides are of value. The 
removal of the bony growth is usually the best treatment. The tech- 
nique of the operation varies with each case. Boenhaupt reported 23 
cases in which the tumor grew from the frontal sinus, in 11 of which it 
communicated with the cranial cavity. It is obvious, therefore, that 

1 I am indebted to Dr. Otto Stein's paper on Symmetrical Osteoma of the Nose for most of the 
data on this subject. 



280 



THE NOSE AND ACCESSORY SINUSES 



osteoma of this region is the most serious from a clinical and surgical 
point of view. 

In the removal of osteoma, if there is no pedicle, it is better to enucleate 
the tumor rather than to attempt to chisel or drill into its substance, 
as it is often so dense as to resist the instruments. 

In one of my cases of osteoma of the epipharynx, the posterior choanse 
were completely blocked. The bone was so dense that it could not be 
removed with a chisel. The only instrument that would penetrate it 



Fig. 210 




Lipoma of the tip of the nose. (Pynchon's case.) 



jWas a trephine. With this a large portion of the tumor was removed 
(through the nose, and nasal respiration was successfully reestablished. 
One year later the nasal occlusion returned. This case should have been 
treated by temporary resection of the superior maxilla. 

Lipoma. — Lipoma of the nose may be external or internal, and is 
usually pendulous. When external it generally affects the alse of the 
nose. The case illustrated involves the tip of the nose (Fig. 210). The 
treatment consists of the excision of the growth. 



MALIGNANT NEOPLASMS OF THE NOSE 281 



MALIGNANT NEOPLASMS OF THE NOSE 

Carcinoma. — Carcinoma of the nose is more rare than sarcoma, and 
usually begins in the anterior portion of the nasal structures, at which 
point there is the greatest physiological irritation. 

Diagnosis. — The diagnosis is based upon (a) the presence of an in- 
tense irregular lancinating pain; (b) a mucopurulent secretion, which 
if ulceration is present is admixed with blood; (c) the characteristic 
ozena or stench of cancer; (d) nasal stenosis more or less marked accord- 
ing to the stage in which the disease is observed ; (e) impairment of vision 
if the ethmoid cells are involved; (/) ulceration of the growth if in an 
advanced stage; and (g) cachexia. (K) In addition to the foregoing 
clinical symptoms it is usually necessary to remove a portion of the 
growth for microscopic examination. D. Braden Kyle properly calls 
attention to the necessity of observing two precautions in securing the 
specimen, namely: (1) That there should be as little laceration and 
irritation on the parts as possible; (2) that the portion removed should 
not involve directly the ulcerated area, which will contain inflammatory 
embryonic connective tissue, and, as pointed out by J. Bland Sutton, this 
cannot be differentiated from sarcoma or from a simple inflammatory 
process with ulceration. If, however, the specimen is taken early, 
before ulceration has occurred, this source of error may be obviated. 

Prognosis. — The prognosis is always grave. 

Treatment. — The surgical treatment of carcinoma of the nose, except 
in the very early stage, is contra-indicated. 

The palliative treatment consists in the local application of orthoform 
powder to ease the pain, and local applications of dilute hydrochloric acid 
and formalin to the ulcerated areas. 

Sarcoma. — Sarcoma of the nose is of slow growth, and is less malig- 
nant that sarcoma in other parts of the body. Unlike carcinoma it 
occurs most often before the fortieth year of life, and is not uncommon 
in infancy and childhood. 

Diagnosis. — The diagnosis is based upon (a) progressive nasal stenosis; 
(b) a mucopurulent nasal secretion, which, in the advanced stage, becomes 
sanguinolent ; (c) more or less slight pain in strong contrast to the intense 
pain in carcinoma; (d) the age of the patient, if below forty years, is 
also of diagnostic significance, though carcinoma occasionally occurs 
before this age; (e) finally, the diagnosis must be made by submitting 
a specimen of the growth to microscopic examination. 

Prognosis. — The prognosis is grave, though not as grave as carcinoma. 
When operated upon early there is a fair chance of recovery. In one of 
my cases operated on by Ollier's method (Fig. 211), there has been no 
recurrence of the sarcoma after six years. 

Treatment. — The treatment in the early stage is surgical, especially in 
view of the slighter malignancy of nasal sarcoma. The growth may 
be removed with a curette, or galvanocautery through the nasal orifices, 
or, if extensive, an external operation may be required. 



282 THE NOSE AND ACCESSORY SINUSES 

Oilier' s Operation. — This operation is performed under general anes- 
thesia, with the head of the patient hanging over the end of the table 
in Rose's position. Postnasal tampons should be introduced to pre- 
vent entrance of blood into the epipharynx and larynx. An incision 
extending from the left ala of the nose, upward over the bridge, and 
thence downward to the right ala, should be made through the cutaneous 
tissue (Fig. 211). A Gigli saw should then be placed at the bridge 
of the nose and all the bony structures along the cutaneous incision 
severed. 

The nose, thus temporarily resected, is then turned downward over 
the mouth. This having been done, the growth should be enucleated 
by blunt dissection, if possible, or if this cannot be done it should be 

Fig. 211 Fig. 212 





Olliei's incision for exposing the nasal cavities for Lateral view of the Oilier 

operative purposes. incision. 

removed by dull curettage. A sharp curette should not be used, as it 
leaves the lymphatic vessels open and may cause septic infection and 
extension by metastasis. Hemorrhage may be considerable, hence the 
postnasal tampons introduced before beginning the operation serve 
as bases against which strips of gauze may be packed to check it. 

In my case, illustrated in Figs. 211 and 212, the hemorrhage was very 
profuse and necessitated the use of normal salt enemata. The transfu- 
sion of normal salt solution would have been better, but as arrangements 
had not been made for it the enemata were substituted. This patient was 
thirteen years old when I first saw her, and was fourteen when I per- 



MALIGNANT NEOPLASMS OF THE NOSE 283 

formed the Oilier operation. She is now twenty-two years of age, and is 
free from the growth. Bony sequestra have been removed from time to 
time, and but little ozena is present. 

Having removed the tumor, the incision should be closed by sutures, 
and the tip of the nose raised into position and fixed with adhesive 
strips. The stitches should be removed on the fifth day. The nasal 
wound should be packed with gauze impregnated with bismuth or the 
compound tincture of benzoin, to prevent decomposition and sapro- 
phytic infection. The intranasal dressing should be removed and 
renewed daily. 



CHAPTEE XIV 

EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. 
FURUNCULOSIS. SCREW- WORMS 

EPISTAXIS (NASAL HEMORRHAGE) 

Epistaxis is a nasal hemorrhage, that is, a bleeding from the interior 
of the nose. While the hemorrhage is usually from the anterior portion 
of the septum (90 per cent, of the cases, according to Casselberry), it may 
occur from any portion of the nasal mucosa. The bleeding is not often 
serious in character, though several deaths have occurred therefrom. It 
is most serious in bleeders, or hemophiliacs, and in arteriosclerosis, 
valvular heart lesion (right side), sarcoma, and pressure on the veins of 
the neck by aneurysm, bronchocele, and intrathoracic tumors. 

Etiology. — (a) Anterior deflection of the septum is the predisposing 
cause of hemorrhage in a large majority of the cases. This portion of 
the septum is richly supplied with blood from the septal artery, a branch 
of the superior coronary, and is exposed to the ingoing current of air, 
which is often loaded with foreign particles. The air, furthermore, 
dries the secretions on the anterior portion of the septum, especially 
if it is deflected in this location. The membrane is quite thin in this 
area. Slight erosion of the mucosa readily gives rise, therefore, to nasal 
hemorrhage. 

(6) Catarrhal inflammation causes chronic hyperemia of the mucous 
membrane, hence the increased supply of blood in the parts contributes 
to the epistaxis. 

(c) A number of febrile diseases are often attended by epistaxis. 
The diseases most commonly thus characterized are typhoid and diph- 
theria. "Black diphtheria/' or hemorrhagic nasal diphtheria, is at- 
tended with a destructive degeneration of the nasal mucosa, submucous 
hemorrhage, and epistaxis. 

(d) The veins on the anterior portion of the septum are sometimes 
varicosed and give rise to hemorrhage. 

(e) Obstruction to the portal circulation may be attended by nasal 
hemorrhage. 

(/) Suppression of the menstrual flow and a severe hemorrhoidal 
hemorrhage is sometimes attended by a vicarious nasal hemorrhage. 

(g) Traumatic epistaxis may result from picking the nose with the 
finger nail or violently blowing it. Intranasal surgery is frequently 
followed by severe nasal hemorrhage. This is especially true after 
operations upon the middle turbinate, the ethmoidal cells, and the 
"swell bodies" or erectile tissue of the inferior turbinated body. The 
(284) 



EPISTAXIS 285 

middle turbinated and the ethmoidal cells receive a generous blood sup- 
ply from the anterior and posterior ethmoid arteries (Plate I, Fig. ]). 
External violence to the nose is often followed by epistaxis or the so-called 
" bloody nose." 

(K) A perforating ulcer of the septum frequently gives rise to epis- 
taxis. The vessel walls are broken down in the destructive process, 
and the granulation tissue upon the border of the perforation bleeds 
upon slight cause. 

(i) Certain constitutional diseases, as hemophilia, Bright's disease, 
purpura, scorbutus, chloremia, leukemia, and arteriosclerosis, are char- 
acterized by nasal hemorrhage, for obvious reasons. Syphilis and tuber- 
culosis of the nose also give rise to epistaxis. 

(j) Sarcoma of the nose, like sarcoma elsewhere, is often attended 
with hemorrhage. 

Treatment. — The treatment of nasal hemorrhage in most cases is 
very simple, as the local application of cocaine or of adrenalin readily 
stops it. In other cases, however, when the cause is a constitutional 
disease, a growth pressing on the veins of the neck, or when the trunk of 
one of the larger septal arteries, as the anterior ethmoidal, is severed in 
an intranasal operation, the bleeding is not so easily checked. 

The hemorrhage may usually be checked by one of the following 
procedures : 

1. Hot nasal irrigation is quite effective in many of the cases when 
the epistaxis is not due to some grave disease. The temperature of the 
water or normal salt solution should be as high as can be tolerated, or 
about 130°. 

2. Ice-water may also be injected into the nose with advantage in oper- 
ative hemorrhage while the patient is under an anesthetic. Only two or 
three injections of four ounces each should be used, as a greater quantity 
might produce serious shock to the brain by sudden or excessive chilling. 
I have frequently resorted to this method of treatment at the close of 
nasal operations when the hemorrhage was profuse, with the most 
gratifying results. 

3. The local application of cocaine or adrenalin often checks the 
hemorrhage when it is of capillary origin. If blood clots are present, 
the nose should first be cleared. The adrenalin extract may be given 
internally for its hemostatic effect. 

4. Blood clots are sometimes allowed to remain in the nose, with the 
idea that they will finally check the hemorrhage. This procedure is 
based upon an erroneous idea. The blood clots only serve to shield 
the bleeding area from such local medicaments as may be used, thus 
hiding the bleeding point from view. The bleeding usually continues 
beneath the clots, hence they should be thoroughly removed at once in 
order to expose the bleeding area to inspection and to make it possible 
to apply such local remedies as may be deemed necessary. 

5. Astringent remedies, such as the nitrate of silver in 5 to 20 per cent, 
solutions, may be made from time to time when the oozing is persistent. 

6. The application of the actual cautery has sometimes proved to be a 



286 THE NOSE AND ACCESSORY SINUSES 

speedy and efficient means of controlling the bleeding; a flat-pointed 
electrode should be used at a cherry-red heat for this purpose. 

7. Local pressure over the bleeding point for a few minutes will 
sometimes control the bleeding. 

8. Tampons in the nose should only be resorted to in those cases in 
which the bleeding persists in spite of all other measures. Their use, as 
a general rule, should be avoided, as they are likely to give rise to condi- 
tions favorable to sepsis. The more completely the nasal chambers 
are packed with gauze the greater the danger. Hence a postnasal 
tampon, with one anterior to it, is the most dangerous of all. This 
method of packing the nose in epistaxis should be avoided except in an 
extreme emergency. 

When bleeding occurs from the anterior portion of the septum, and 
it becomes necessary to introduce a tampon, I would, advise the use of 
a Bernay tampon cut into the form of a nasal splint, as recommended 
by Simpson. It absorbs less of the secretions, and is easily introduced 
and removed without further injury to the diseased mucous membrane. 
The interior of the nose should first be covered with subnitrate of 
bismuth by insufflation to prevent decomposition of the secretions. 



RHINOSCLEROMA 

Synonyms. — It is probable that a rare lesion described as chorditis, 
chronic hypertrophica inferior, and what is known as Stoerk's blennor- 
rhea are identical with rhinoscleroma. 

Definition. — Rhinoscleroma is characterized by a cartilage-like hard- 
ness and nodular enlargement of the nose and other portions of the 
upper air passages. The affected tissues have no tendency to ulceration 
or to inflammatory reaction either in the growth or in the contiguous 
parts, although rhinoscleroma frequently affects the other divisions of 
the respiratory tract. 

Etiology. — But little is known of the etiology of the disease beyond the 
fact that it is due to a specific microorganism, the bacillus of rhinoscle- 
roma, and that it is chiefly confined to Austria and southwestern Europe. 
About 800 cases have been reported, and of these, about 20 occurred in 
America, but a large majority of these were born in Poland and Austria. 
It usually begins in youth, and most cases are observed between the 
ages of fourteen and forty-five. Sex seems to have no influence. Heredity 
seems to be a negative factor, though there is apparently a family pre- 
disposition to the disease. It is now generally regarded as a contagious 
disease. 

Bacteriology. — The hard, cartilage-like nodules may affect the skin, and 
the mucous membrane of the nose, pharynx, larynx, and trachea. They 
spread with greater freedom in the mucosa than in the skin. The hard, 
nodular masses, or plaques, contain the encapsulated bacillus of rhinoscle- 
roma, which is similar to Friedlander's bacillus, though the latter is not 
always encapsulated. The bacillus of rhinoscleroma is more rod-shaped 



RHINOSCLEROMA 287 

and stains by Gram's method, is motile, non-spore bearing, and aerobic. 
It always has a capsule in culture, as well as in the tissues. It occurs 
singly and in pairs. Gelatin plates show yellowish-white granular 
bodies in two or three days. In gelatin tubes the growth appears along 
the needle track as a whitish granular line, with an almost hemispherical 
elevation on the surface. The growth in the tube has the appearance 
of a round-headed nail. When grown upon agar it appears as a dirty 
whitish moist layer on either side of the needle track. On potato the 
growth is creamy white. It grows rather rapidly at a temperature of 
37° C. It is pathogenic for mice, guinea-pigs, and rabbits. 

Pathology. — The histological changes are inflammatory in character 
and usually begin on the nasal septum, trachea, or larynx. In rare 
instances the reverse course is pursued. The skin and mucous membrane 
of the nose assume a smooth nodular appearance of cartilage-like consist- 
ency, which pits little, if at all, upon probe pressure. The parts are 
sensitive to the touch, but are otherwise free from pain. Kaposi has 
likened the external appearance of the nose to keloid. According to 
Goodale the affected tissues consist histologically of certain typical 
elementary lesions. The substance of the swelling is composed of large 
plasma cells, irregularly distributed in all layers of the mucous mem- 
brane, and in the submucous tissue. They accompany the bloodvessels 
in the new portions of the growth. The plasma cells do not contribute 
directly to the hypertrophy, but it is possible that they become changed 
partly into spindle cells, and then give rise to the formation of new 
fibrillary tissue. Two forms of retrograde metamorphosis occur in the 
plasma cells. These may be transformed into swollen, hydropic, so- 
called Mikulicz cells, or into hyaline degenerated cells, probably 
identical with the so-called Russell's fuchsinophiles, described under 
Colloid Degeneration. The hydropic cells lie close together, have a 
distinct contour and spongy cytoplasm dilated into large masses, in 
which there is a smaller mass within a faceted nucleus. In this stage 
one often sees from six to eight bacilli in the cells near the nucleus 
which lie always at regular distances. 

This stage appears, however, to be rapidly finished, and when the 
cell membrane breaks, the fluid contents, together with some of the 
bacilli, find an exit and fill some of the nearest lymph spaces. These 
cells are, however, intimately related to the direct action of the bacilli. 

Symptoms. — The changes in the external appearance of the nose, 
while presenting many of the characteristics of keloid, are, nevertheless, 
rather easily differentiated from it by the whole symptom complex. 
The tissue at the tip of the nose becomes infiltrated, hard, and nodular. 
The nose broadens and becomes firmly fixed to the face. The tissues 
become more and more thickened, until the breathing is more or less 
occluded. The color of the skin varies frcm a red to a bluish or brown- 
ish red. The skin is traversed by small bloodvessels, and is usually 
slimy, though it may be finely wrinkled. The extension of the growth 
is rather slow, requiring several months to reach the epipharynx. The 
infiltration often interferes with the movements of the lips, the fauces, 



288 THE NOSE AND ACCESSORY SINUSES 

and the larynx, and very rarely with that of the eyes and ears. There is 
no tendency to ulceration and discharge, or to edema and inflammation 
of contiguous parts. 

Laryngeal stenosis may give rise to serious or even fatal dyspnea, 
otherwise the disease does not materially affect the general health. 

Diagnosis. — Rhinoscleroma should be differentiated from syphilis, 
epithelioma, and keloid. The disease is exceedingly rare in this country, 
hence it is natural to infer that a suspected case in a native-born 
American is probably not rhinoscleroma, but that it is either syphilis, 
epithelioma, or keloid. Rhinoscleroma presents a hard, nodular growth, 
which usually begins at the anterior end of the nose and spreads grad- 
ually to the deeper recesses of the respiratory tract, without pain, but 
with some tenderness upon pressure, and without tendency to ulcer- 
ation or inflammation of the surrounding tissues. In syphilis there is 
inflammation, while in epithelioma there is pain, ulceration, and dis- 
charge. In keloid the similarity is often so striking that it may be 
necessary to demonstrate the absence or presence of the germ of 
rhinoscleroma in order to make a differential diagnosis. 

Treatment. — Thus far the extirpation of the diseased tissue has been 
tried with negative results as to the cure of the disease. The surgical 
extirpation of the diseased tissue has almost invariably been followed 
by recurrence. Tracheotomy should be performed when suffocation is 
imminent. Thiosinamin apparently softens the tissue (Glass), as it does 
in keloid; it may, therefore, be of some therapeutic value. A reliable 
method of treatment, however, has not been discovered. Freudenthal 
suggests the injection of Coley's fluid, as in sarcoma. The iodides and 
mercury have been tried with but little success. The arrays have been 
used by Emil Mayer with apparent success, though it is probable that this 
mode of treatment will prove disappointing, as have all other methods. 



FURUNCULOSIS OF THE NOSE 

Definition. — Furunculosis of the nose is a superficial abscess forma- 
tion which may occur in any part of the nose, and does not differ 
materially from the same process in the other parts of the body. 

Etiology. — The abscess is usually located on the anterior portion of 
the septum, i. e., that portion covered by the vestibular skin, and is usually 
due to an injury, as from picking the nose. One or more furuncles may 
be present at a time or they may occur in quick succession. The hair 
follicles of the vestibule offer favorable sites for the infection. If they 
recur frequently the cartilaginous septum becomes involved. Recur- 
rence most commonly takes place in the young or the middle-aged, 
especially in those in whom an impoverished state of the blood exists. 
The infectious fevers are often attended with nasal furunculosis. 

Symptoms. — There is more or less throbbing pain, swelling, redness, 
and tenderness. Elevated areas characteristic of boils may be seen upon 
inspection. When they are well advanced the centre of the elevation 



SCREW-WORMS IN THE NOSE 289 

is yellowish from the contained pus. The pain is often intense, on 
account of the closely attached and unyielding nature of the tissue 
composing the parts. 

Treatment. — If seen early, before pus formation, the application of 
a 50 per cent, solution of ichthyol or a 10 per cent, glycerin solution 
of carbolic acid on a pledget of cotton will often abort the process. If 
pus has formed, they should be incised from within the nasal cavity 
with a sharp bistoury. After incision their cavities should be irrigated 
with warm boric acid solution and the tincture of iodine applied. 



PHLEGMONOUS RHINITIS 

This is somewhat different from furunculosis, in that it is an abscess 
formation affecting the nasal mucous membrane. The condition is 
rare except as the result of an operation or other traumatism. (See 
Abscess of the Septum.) 



FOREIGN BODIES IN THE NOSE 

Foreign bodies in the nose may be animate or inanimate. 

SCREW- WORMS IN THE NOSE 

Screw-worms in the nose have been reported by M. A. Goldstein, 
Hal Foster, and J. S. Steele in most interesting and instructive articles, 
wherein it is shown that their invasion of the human being is not as 
rare as might be supposed. (See Foreign Bodies in the Ear.) 

The screw-worm fly is attracted by a foul-smelling discharge from the 
nose or the ear, and it need be in the nose but for a moment in order 
to deposit its eggs. Dr. Steel narrates a case illustrative of this point. 
A railway engineer, while walking across the plaza of a Mexican city, 
inhaled a fly into one nostril, which he immediately blew out through the 
other. Twenty-four hours later fulness and pain between the eyes was 
noted, which increased for three days, when he came under observation. 
He was affected with syphilitic rhinitis with necrosis of the nasal septum, 
which accounted for the fly being attracted to his nose. About one 
hundred worms were removed with the douche and forceps. Calomel 
fumes were inhaled, which seemed to exterminate all that remained, 
as they gave rise to no further symptoms. 

Foster removed two hundred and seven worms from the nose of an old 
Irish woman who was subject to epileptic fits, during which she would 
fall to the gound. Following one of these seizures she noted an itching 
of the nasal mucosa, which was accompanied by headache and sneezing. 
She was told that she had hay fever, and large doses of quinine were 
administered. Two days later the nose began to bleed and to give forth 
19 



290 THE XOSE AXD ACCESSORY SINUSES 

a very offensive discharge. The eves were closed from swelling of the 
subcutaneous tissue of the face, and she was in such discomfort that 
she was unable to sleep. 

Upon examination the nostrils were found to be entirely filled with 
worms. Inhalations of chloroform were administered, which rapidly 
rendered them lifeless, after which they were readily removed with 
forceps. The live worms clung with tenacity to the tissues when force 
was applied in their removal. There was great destruction of tissue, 
and the temperature reached 102°. There was a bulging of the anterior 
part of the nose as a result of the penetration of the worms at this point. 

Goldstein's case was that of a farm laborer who slept outdoors in 
a hammock. He was affected with syphilitic rhinitis, which offered an 
ideal attraction to the Texas screw- worm fly. When examined, the nose 
was found to be filled with the eggs of the fly; five hundred were removed 
with the curette. The curettage was thoroughly done, considerable 
tissue being removed with the eggs. Forty-eight hours later the patient 
suffered excruciating pain in the nostrils, which were completely occluded. 
The skin over the frontal sinus was red and tightly drawn. On the 
sixth day there was swelling over the dorsum of the nose near its centre. 
This was incised and considerable pus evacuated. Several worms were 
subsequently removed through this opening. 

Chloroform is the most effective remedy, and may be administered by 
inhalation or in diluted solution with a syringe. Calomel fumes are 
also of value, but do not act as quickly as chloroform. Steele's case 
shows that its effects were apparent after about four hours, whereas 
chloroform is effective within a few seconds or minutes. 

Inanimate foreign bodies include almost every kind of inert substance 
small enough to be introduced into the nose, and some that are too large 
to be introduced into the nose, at least through the nasal opening. One 
such case was under my care and gave the history of having received a 
wound thirty years previously from the explosion of a musket. The left 
eye was destroyed at the time. Upon removal of the foreign body it 
proved to be the breech pin of the musket which exploded thirty years 
previously. The mass of iron, as large as the first joint of the thumb, 
still preserved its mechanical form, as the screw threads and the tubular 
space for the flash powder. The cap pin was also intact. In most in- 
stances the foreign body is voluntarily introduced by the patient. Young 
children have an inordinate desire to introduce such substances into 
their noses, hence most cases occur in young children. Idiots and the 
insane also delight in putting foreign substances into their noses. 

The removal of the foreign body may be accomplished through the 
anterior nasal opening without the use of a general anesthetic, though 
in some cases this may be necessary. Forceps with good, grasping tips 
should be used to seize it and, after dislodging it, to remove it. 



CHAPTEE XV 

THE SURGICAL CORRECTION OF EXTERNAL NASAL 
DEFORMITIES 

The surgery of external deformities of the nose is being more and 
more relegated to rhinologists, for various reasons, chief among which 
are : (a) The rhinologist has a more intimate knowledge of the structures 
of the nose and can therefore more intelligently conserve and utilize 
them in reconstructing it; and (b) the rhinologist of modern times 
is better trained and more skilled in surgical principles and practice 
than formerly. For these and other reasons a chapter on some of the 
simpler nasal deformities, especially those which can be corrected by 
intranasal and subcutaneous routes, is introduced in this chapter. 

Fig. 213 








a 




Traumatic lateral displacement of the nose to the right: a, depressed left nasal bone. 

The Twisted or Crooked Nose. — This type of deformity may be due 
to the congenital maldevelopment of the structures of the nose and 
face, but it is generally caused by external violence to one side of the 
nose, which results in an irregular lateral displacement of the septum 
and tip of the nose. The nasal bone upon the side receiving the blow 
may also be dislocated laterally, or depressed (Fig. 213, a). 

The Author's Operation. — First Operation. — To correct this deformity 
the septum should first be straightened by the submucous resection of 

(291) 



292 



THE NOSE AND ACCESSORY SINUSES 



the deformed cartilage and perpendicular plate of the ethmoid bone. 
The cartilage forming the ridge of the nose should be left wide, as it will 
be needed in the third operation. If the vomer is deformed it should 
also be included in the submucous resection. 

Second Operation. — The depressed nasal bone (Fig. 213, a) should 
be fractured from its attachment and reset in its normal position. This 
should be done two or more weeks after the submucous resection. 
The technique is as follows: 



Fig. 214 



Fig. 215 





The intranasal incision at the tip of the left 
nasal bone. One blade of the steel forceps is 
inserted through this between the skin and the 
nasal bone, the other grasps the tissue anterior 
to the middle turbinated body (a). 




The Steel septum forceps grasping the nasal 
bone (a) to fracture it preliminary to resetting 
in its normal position. 



An intranasal incision should be made with a small scalpel through 
the mucous membrane of the outer and anterior wall of the nose at the 
inferior border of the nasal bone (Fig. 214, a). Hajek's semisharp sep- 
tum periosteal elevator should then be introduced through the incision, 
and the skin and periosteum over the nasal bone stripped loose. 

The Steel, Asch, or other stout septum forceps should be introduced 
into the nostril thus prepared, and one blade insinuated through the 
incision and between the skin and nasal bone, while the other remains 
free in the nose (Fig. 215). 

The nasal bone should then be firmly grasped between the blades of 
the forceps, and rotated upon the axis of the blades, and the nasal bone 
completely fractured from its attachments. 

The nasal bone should be reset in its normal position and held there 
by means of Carter's nasal splint, or an intranasal cotton tampon impreg- 
nated with powdered bismuth until union takes place; this may be 
removed in three or four days. Carter's nasal splint, is, however, the 
best device for this purpose. 



THE SURGICAL CORRECTION OF NASAL DEFORMITIES 293 



Third Operation. — At a subsequent time the union of the septal 
cartilage with the nasal bones should be overcome via the nasal route. 
The incision should be made through the mucous membrane and carti- 
lage, beginning at the junction of the nasal bones and the cartilaginous 
septum just beneath the skin at the ridge of the nose. If the cartilage has 
previously been removed by submucous resection the lower end of the 
incision should extend to the area of the removed cartilage (Fig. 216). 
The mucous membrane on the opposite side of the cartilage need not be 
included in the incision unless greater mobility is to be thereby gained. 
The incision should extend entirely through the cartilage, which other- 
wise will not remain in the new position in which it is to be placed. 

Push the tip of the nose forcibly beyond the median line, and note 
whether it tends to return to its former malposition. If it does, ascertain 
where the point or points of resil- 
iency still exist. If at the floor Fig. 216 
of the nose, sever the attachment 
at this point and so continue until 
the whole portion of the nose below 
the nasal bones remains in the 
median line without support. If 
the vomer is still present it should 
be fractured from the premaxillary 
bone by twisting it with the Asch 
septum forceps until it is perfectly 
pliable. Having done this, the 
vomer should be reset and sup- 
ported in such a position as to 
favor the correction of the external 
deformity. 

If the skin and cartilage at the 
ala on the side toward which the 
tip of the nose formerly inclined 
interferes with the displacement 
toward the opposite side, an in- 
cision should be made at the junc- 
tion of the ala and skin of the 
cheek, and the ala and cartilage 

elevated from the bone at the margin of the pyriform opening until 
they no longer interfere with the lateral displacement of the nose. 
When the tip of the nose is displaced laterally a crescentic wound is left 
(Fig. 216, a). This area may be allowed to heal by granulation or it 
may be covered by a Thiersch graft, after two or three days, when new 
granulation tissue has covered the denuded area. 

The whole lower portion of the nose, being thus rendered perfectly 
mobile, should be fixed in the median line, or rather beyond it, as the 
tendency will be for it to return to its former position. To hold the nose 
in its new position the author's septum clamp (shown in Fig. 216, b) is 
placed astride the cartilage along the ridge of the nose, the blades approxi- 




ia— 



/ 



The nasal splint (b) held in position by the 
anchor cord (c) fixed behind the ear. a, the 
crescentic area left after the nose is reset in the 
median line. 



294 



THE NOSE AND ACCESSORY SINUSES 



mated by tightening the milled screws, and a stout linen cord looped over 
the distal end of the clamp. The other end is theft looped behind the ear 
and the knot drawn until the nose assumes the position desired by the 
surgeon. The portion of the thread which goes behind the auricle 
should be passed through a small rubber tube to prevent it from cutting 
the skin (c). This splint should be worn for one week or even longer to 
allow union of the tissues in the new position. The tension of the loop 
should be regulated daily. The splint may be removed and reinserted if 
it becomes necessary to cleanse the nasal chambers. A bandage should 
be placed around the head to hold the auricle in position. 



Fig. 217 




Traumatic deformity of the face; the nose and upper lip dislocated downward in a 
cyclone disaster. 



Dislocated Nose. — Violent force, as a cyclone, may cause the lower 
portion of the nose and the upper lip to be dislocated downward, as shown 
in Fig. 217. In this case the nose and upper lip were dislocated down- 
ward and had united to the tissues beneath. The openings of the nostrils 
were on a level with the gums, hence the nostrils were almost completely 
obstructed. The triangular space shown in Fig. 218 was filled with 
scar tissue, which is shown dissected away with the skin. The upper 
lip and cheeks were freely dissected loose and the sutures introduced 



THE SURGICAL CORRECTION OF NASAL DEFORMITIES 295 

beginning at the lower angles of the triangular wound. When the 
sutures were tied the end of the nose and upper lip were drawn into 
their natural position. Large rubber drainage tubes were then placed in 
each nasal chamber for three or four days to prevent adhesions and to 
sustain the nose in its new position. Irrigation with warm normal salt 
solution was continued until crusts ceased to form. The final result is 
shown in Fig. 219, in which the nose is greatly shortened. 



Fig 218 



Fig. 219 





Operation for the correction of traumatic 
dislocation of the nose and upper lip: a, 
the area of tissue dissected loose to per- 
mit the displacement of the lip and nose. 
(Author's case.) 




The result of the plastic operation. 



The Aquiline or Hump Nose. — Occasionally the possessor of an 
aquiline nose, especially if the "hump" is quite prominent, is anxious to 
have the "hump" removed or reduced. This may be done by external 
incision, or subcutaneously through the nose. Preference should be 
given to the intranasal route, because it does not produce a visible scar. 
I cannot conceive of a deformity of this kind that may not be removed 
via the nasal chambers. 

External Operation. — If, however, an external operation is preferred, it 
should be made in the median line of the nose, over the area of deformity. 
The skin and the periosteum should then be raised on either side, 
exposing the prominent nasal bones (Fig. 220). The elevated flaps 



296 



THE NOSE AND ACCESSORY SINUSES 



Fig. 220 




External operation for the removal of the 
"hump" from the nose. 



should be pulled aside with retractors by an assistant. The surgeon 
should then carefully remove enough of the projecting nasal bones to 

reduce the deformity to the degree 
suggested by the patient. The 
cutanoperiosteal flaps should then 
be coapted with adhesive strips 
and allowed to heal by first inten- 
tion. Stitches should be avoided 
if possible, as they add to the 
prominence of the linear scar in 
the median line of the nose. The 
adhesive strips may be removed at 
the end of from three to five days. 
Intranasal Operation by the 
Author's Method. — This method of 
operating should usually be chosen, 
as it is not attended with an exter- 
nal scar. 

Technique. — (a) Local or gen- 
eral anesthesia. 

(b) Thoroughly irrigate the nasal chambers with warm salt or boric 
acid solution, or otherwise clear the nose of crusts, secretions, and 
bacteria. 

(c) Introduce a scalpel into one nasal chamber until its point reaches 
the lower border of the nasal bone, then make an incision through the 
mucous membrane and pass the blade of the knife between the nasal 
bone and the skin covering it (Fig. 214, a). 

(d) Withdraw the knife and introduce a small elevator of the Freer 
type and separate the skin from the anterior portions of both nasal bones. 

(e) Withdraw the elevator and introduce the author's reverse chisel 
(Fig. 221), and with a downward and forward pull (parallel with the 
ridge of the nose) shave the anterior borders of the nasal bones until 
the hump is sufficiently reduced (Fig. 222). 

(/) The skin over the operative field should be gently massaged every 
three hours to prevent the deposit and organization of a plastic exudate 
over the bones previously reduced. Heat, or the application of the 
leukodescent light over the nose, will also control the amount of inflam- 
matory deposit. 

(g) Compression with a nasal pad and a roller bandage may be used 
instead of massage, heat, etc., if these are not available. 

The Long or Drooping Nose. — This type of nose is occasionally 
seen. I have twice corrected the deformity. The method pursued by 
me has been the resection of a wedge-shaped piece of the nasal septum 
through the nasal orifice. 

Technique. — (a) Cocaine anesthesia as for the submucous resection 
of the septum. 

(b) Make two incisions through the mucous membrane and cartilage 
to the opposite mucous membrane, as shown in Fig. 223. Connect the 



THE SURGICAL CORRECTION OF NASAL DEFORMITIES 297 

divergent ends of the incisions at the ridge of the nose by an intersect- 
ing incision, which should separate the cartilage from the skin of the 
nasal ridge. 

(c) Remove the triangular piece of cartilage with an elevator. 

(d) Draw the whole end of the nose upward with a sling composed 
of strips of adhesive plaster. 

(e) At the end of from four to eight days remove the adhesive strips. 



Fig. 221 




The author's reverse chisel for subcutaneous correction of nasal deformities. 



Fig. 222 



Fig. 223 





The author's method of removing the "hump 
from an excessively aquiline nose. 



The author's method of shortening a long 
overhanging nose. The triangular piece of 
cartilage (a) is removed via the nostril and the 
gap closed by lifting the tip of the nose up- 
ward and securing it in place with adhesive 
straps applied externally. At the end of four 
to eight days the straps are removed, union 
being complete. 



After-treatment. — To prevent local infection and assure firm union of 
the septal wound, introduce pledgets of cotton saturated with a 10 per 
cent, glycerin solution of ichthyol every four hours for three days. 
The ichthyol is antiseptic and the glycerin promotes osmosis of serum 
from the bloodvessels which washes away any bacteria that chance to 
invade the region of the wound. 

Remarks. — When the nose is shortened in this way there is no 
redundancy of skin, as it contracts until the normal tension is estab- 
lished. 

Paraffin Injection. — The use of paraffin has passed the stage of experi- 
mentation, and is, in fact, a well-established procedure in surgery, espe- 
cially in nasal work. It is used principally in the correction of congenital 



298 



THE NOSE AND ACCESSORY SINUSES 



and acquired deficiencies. One of the most important locations for its 
use for cosmetic purposes is the bridge of the nose, in the character- 
istic saddle nose. The various locations and conditions where paraffin 
has been used about the ear, nose, and throat are as follows: 

1. Saddle noses following trauma, syphilis, and cretinism. The case 
shown in Fig. 224 was due to cretinism. The patient is a graduate 

of a High School of Chicago, and 



Fig. 224 




is an intelligent young woman 
twenty-four years old. 

2. Following operations on the 
frontal sinus to correct the frontal 
deformity. 

3. To overcome the collapse of 
the alae nasi. 

4. Intranasal injections into the 
inferior turbinated body in rhinitis 
atrophica. 

5. Following resection of the 
superior maxillse to fill up the defect. 

6. Partial reconstruction of the 
inferior maxillae following necrosis 
and resection for malignancy. 

7. Secondary repair of harelip, 
when there is great atrophy of the 
premaxillary bone. 

8. In the region of the postnasal 
space when defect of speech (rhino- 
lalia pata) results from the operation 
for cleft or immovable palate. 

9. Following mastoid operations to fill up large retro-auricular defor- 
mities. 

The paraffin may be injected either hot or cold, depending upon the 
firmness of the paraffin required. The hot becomes the firmer after 
cooling, hence for the correction of a saddle nose the hot paraffin may 
be used, although the cold is preferable and less dangerous. Cold 
paraffin should be used intranasally to build up the inferior turbinated 
body. 

The instrument required for these procedures is the paraffin syringe 
(Fig. 225), which may be used for either the hot or cold paraffin. 

The paraffin which is to be injected hot is kept in an ounce bottle, 
the cold in tubes, which are especially prepared for the syringe. 

Technique. — If hot paraffin is to be used, place the bottle in boiling 
water until the contents liquefies, then fill the syringe with it by withdraw- 
ing the piston. Then turn the screw head from left to right until the 
paraffin comes out of the needle in the shape of a thread. Then intro- 
duce the needle into the cavity to be injected and continue to turn the 
piston slowly until the desired amount has been injected. If the cold 
paraffin is used, it is not necessary to heat it. Insert a cylinder of it 



Congenital saddle nose due to cretinism. 



THE SURGICAL CORRECTION OF NASAL DEFORMITIES 299 

in the syringe and by turning the screw handle of the syringe force the 
paraffin through the needle into the subcutaneous tissue until the desired 
amount is deposited. An assistant should turn the screw handle while 
the surgeon molds the paraffin beneath the skin. The needle should 
be introduced one-half inch above the upper limit of the depression to 
avoid the subsequent extrusion of the paraffin. 

Fig. 225 




Beck's paraffin syringe. 



The opening caused by the introduction of the needle is sealed up by a 
small pledget of cotton moistened with collodion. Considerable bleeding 
from this point sometimes occurs, and pressure should be applied for a 
few minutes or until bleeding ceases. It should then be sealed up. 

In submucous injections an antiseptic gauze pad should be inserted for 
a few hours to control the slight oozing and prevent possible infection. 



300 THE NOSE AND ACCESSORY SINUSES 

To prevent the spread of paraffin into the neighboring tissues, as the 
eyelid, in injecting the bridge of the nose, where a great deal of loose 
areolar tissue is present, it is good practice to have an assistant hold 
his fingers firmly against the underlying bone on each side of the area 
to be injected. Before complete hardening of the paraffin takes place, 
it should be molded to the desired form. The operation may be per- 
formed in one or more sittings according to the discretion of the surgeon. 
It is safer to inject paraffin at several sittings, because one can always 
add to the amount, but if too much is injected, it is very difficult to 
remove it. 

The complications following injection are: 

1. Infection. 

2. Hematoma. 

3. Embolism. 

Each is comparatively rare. The first complication should be guarded 
against by observing the strictest antiseptic precautions in sterilizing 
the paraffin, the syringe, the field of operation, and the hands of the 
operator and assistants. 

Hematoma is controlled by pressure, and if it is very large, it may 
require evacuation, followed by the application of ice and afterward 
warm applications to cause absorption. 

Embolism has been reported twice in the literature, and in both cases 
ether was injected hypodermically in dram doses. The operation was 
successful. 

The change that takes place in the injected mass is at first a reactive 
inflammation forming a fibrous capsule, which soon throws out tra- 
becular, which ramify the paraffin mass in all directions, until the latter 
is held in a meshwork of fibrous tissue. It has been found that after a 
period of six months or a year considerable paraffin has been absorbed, 
connective tissue having taken its place. In cases injected several years 
ago the mass has remained about the same size as when first injected. 
Such a mass after organization is known as paraffinoma. Exposure to 
excessive heat, as in foundries, and during high and long-continued fevers, 
as typhoid and pneumonia, has very little effect on the injected mass; 
traumatism, however, such as a blow on the nose, has changed the 
contour and location of the paraffin mass. 

Special Technique. — Saddle nose and other malformations of the nose. 

1. To fill up a defect: Thoroughly prepare the field of operation and 
place the patient in a recumbent posture. Introduce the needle of the 
syringe beneath the skin from above and fill up the defect either at one 
or in several sittings. Do not dissect the skin loose from the under- 
lying bone, as a hematoma will form and may become infected. 

Stop oozing by compression, and after the paraffin is injected, close 
the puncture with collodion cotton. No after-treatment is required 
(Figs. 226, 227, and 228). 

2. To stiffen collapsed alse of the nose: The needle point is intro- 
duced between the cartilage and the skin along the whole alar area; 
inject a very small particle of paraffin to bring about the desired effect. 



THE SURGICAL CORRECTION OF NASAL DEFORMITIES 301 

3. To reconstruct the inferior turbinated body following atrophic 
rhinitis: Thoroughly cleanse the mucous membrane of pus and crusts. 
Anesthetize with a 5 per cent, solution of cocaine that portion of the 
turbinated body which is to be penetrated by the needle. If a stronger 
solution is used, too much contraction will follow. Inject slowly by 
turning the screw head from left to right, and as the needle is withdrawn 
a track of paraffin is left along the course of the needle. Apply an 
intranasal tampon for a few hours. Keep the parts thoroughly clean. 
It is at times necessary to reinject the different areas. The mucous 
membrane may be too thin from atrophy to retain the paraffin. 



Fig. 226 



Fig. 227 



Fig. 228 






/ 




Traumatic saddle nose: a, a, showing the needle intro- 

point at which the needle duced one-half inch above the 
should be introduced. upper margin of the deformity. 



Showing the depression filled 
with paraffin. 



4. To correct the deformity following the frontal sinus operation: 
Cleanse the skin, introduce the needle point in different directions, 
and insert the paraffin, as the scars are usually very firm and are not 
easily elevated. Extreme care must be taken not to pass the needle too 
deep, as the posterior table may be injured. 

5. To correct the defects after the mastoid operation: Make a pre- 
liminary dissection of the skin, which is usually firmly adherent to the 
bone. This may be done by making a small incision through which 
a small elevator is introduced. Squeeze out all the blood and fill the 
cavity with paraffin. Close the incision by one or two horsehair sutures 
or adhesive plaster. 

6. To correct defects caused by excision or disease of the upper or 
lower jaw: One must be guided by the disease present and apply the 
principles mentioned above. One of the most common defects is caused 
by necrosis following decayed teeth, and secondary periostitis. 



302 



THE NOSE AND ACCESSORY SINUSES 



COLLAPSE OF THE AL-ffi NASI 

Etiology. — Collapse of the wings of the nose is sometimes associated 
with prolonged nasal obstruction and mouth breathing. Lambert Lack 
suggests that the open mouth, with the resultant drag on the sides of 
the nose, and the atrophy of the dilator muscles of the alae from pro- 
longed disuse are the chief factors in producing this condition. The 
condition may also be due to senile changes. 

Symptoms. — The nasal orifices are greatly narrowed, often mere slits, 
and the alae are flaccid and collapse upon inspiration. Under normal 
conditions the alae dilate and are firm and resilient. 

Treatment. — If the collapse is due to unilateral nasal obstruction, the 
cause of this obstruction should be removed. In some instances this 
is followed by a cessation of the collapse, especially if the condition is 
of comparatively recent occurrence. In older cases the collapse of the 
alae persists. 



Fig. 229 



Fig. 230 





Walsham's operation: Collapse of the ala Schema showing Lambert Lack's method of 

nasi corrected by a roll of mucous membrane overcoming collapse of the abe nasi. The 
from the septum. flaps a an d 6 are ma de from the septum, and 

are about one-eighth of an inch wide. The 
upper surface of each flap is denuded of mucous 
membrane, and the nasal walls against which 
they are reflected are curetted to encourage 
adhesion. The flaps are held in position by a 
single suture in each flap. 

Lack advises that the patient practise dilating the nostrils against 
resistance. ^ He urges them to stand before a mirror for five or ten 
minutes twice a day and lightly compress the alae with the thumb and 
finger, and dilate the nostrils to their fullest extent. This method gives 
results in recent cases, whereas in chronic one's, in which there is com- 
plete paralysis of the dilator muscles, it is ineffective. (See Paraffin 
Injections.) 

Soft and hard rubber rings (Guye) have been worn to keep the nostrils 
patulous, but the discomfort attending their use is quite objectionable. 

Walsham recommends elevating a narrow strip of mucous membrane 
from the anterior portion of the septum with an attachment above, and 



COLLAPSE OF THE ALM NASI 303 

then rolling it into a mass at the upper angle of the nostril (Fig. 229), 
stitching it in position where it mechanically prevents the collapse of the 
ala. Lambert Lack suggests the most ingenious and apparently the best 
method in obstinate and troublesome cases. "The operation consists 
in turning up a piece of cartilage as well as mucous membrane from the 
septum and stitching it across the top of the nostril at right angles to 
the septum, so as to push the ala forcibly outward. An L-shaped in- 
cision is made through the mucous membrane on one side of the nasal 
septum and the mucous membrane detached from the cartilage. A 
small piece of mucous membrane at the top, and extending a little on to 
the outer wall of the nostril, is then cut away so as to leave a bare surface, 
to which the cartilaginous flap becomes adherent. The knife is then 
passed completely through the septum, and a small quadrilateral piece 
of the septum, with the mucous membrane on the opposite side left intact, 
is cut. This flap should be about one-half inch long and one-eighth inch 
broad. It is fixed to the roof and outer wall of the nostril with a single 
stitch. A similar piece is then turned up on the other side (Fig. 230)." 



CHAPTER XVI 

CHRONIC GRANULOMATA OF THE NOSE, THROAT, AND EAR 
LUPUS OF THE NOSE 

Definition. — Lupus vulgaris is a chronic disease of the skin and 
mucous membrane, characterized by the formation of nodules of granu- 
lation tissue. It passes through a number of phases, and terminates 
by ulceration or atrophy with scar formation. The cause of the disease 
is the tubercle bacillus. 

Etiology. — Lupus of the nose and upper air passages is practically 
always associated with, or is secondary to, a lupoid condition of the skin 
of the face. Rare instances of primary lupus of the pharynx and larynx 
have been reported by Emil Mayer, Rubenstein, and others. 

Females are more often affected than males, and it is more common 
in the country than in the city. It is most common in middle life, though 
it occurs at all ages. An abraded or diseased mucous membrane predis- 
poses to its development. While lupus is due to the tubercle bacillus, 
there is a clinical distinction between it and tuberculous ulceration. 
Lupus is slow and insidious in its development, and is not necessarily 
associated with pulmonary tuberculosis. It has a tendency to heal, 
cicatrize, and recur, and does not often result in death from pulmonary 
involvement. 

Symptoms. — Lupus of the nose generally begins on the anterior por- 
tion of the cartilaginous septum or upon the skin around the nasal orifice. 
It may spread from the septum to the inner wall of the ala. It appears 
as small nodules which coalesce and ulcerate, and it may disappear by 
absorption. The reparative process takes place but feebly at the margins 
of the ulcer, thus forming a pale-bluish, smooth cicatrix. The ulcers 
reappear and then disappear. This process may continue for years 
without spreading to other regions. The nodules are firm and well 
marked. The disease rarely attacks the cartilage and never the bones. 
One or both nostrils may be affected, and there may or may not be 
stenosis. The discharge varies with the stage of ulceration. At the 
onset it is thin and watery, and later becomes thick and even fetid, 
especially after crusts appear. Pain and tenderness may be present, 
though I have seen cases in which they were absent. Itching is some- 
times complained of. 

Deformity may be present if the alse are involved; when limited to 
the septum it is rarely present. 

I reported a case which was under the care of the late Dr. Max 
Thorner, of Cincinnati, for about four years. Subsequently it was 
(304) 



LUPUS OF THE NOSE 305 

under my care for about the same time, and is now under the care of 
a confrere, who informs me that the ulcerous condition has yielded to 
applications of the high-frequency currents of electricity. It should 
be noted, however, that the patient spent the winter in the South, 
and that while under my care the ulcer disappeared spontaneously each 
summer. (The case has more recently been reported as cured with 
bismuth paste, thus conclusively proving the apparent cures to have 
been remissions rather than cures.) 

The case has thus been under nearly constant observation for about 
twenty years. The patient is about forty-seven years of age, and is in 
robust health, never having had any pulmonary symptoms. She says 
her brother has a similar condition in 
his nose. I inoculated a guinea-pig FlG - 231 

with the tissue removed by curettage, 

and in six weeks the postmortem showed \ / 

extensive tuberculous lesions in the p / 

neighboring glands and in the mesentery. 
The ulcer (Fig. 231) was superficial, 
irregular in outline, and had a somewhat 
nodular surface covered with crusts. 
It bled easily upon probing, was pain- 
less, and disappeared during the summer 
months, leaving a whitened, rather 
smooth, cicatricial surface. It reap- 
peared in the autumn of each year, 
only to disappear the following sum- 
mer. This case seems to be primary f 
in the nose, and shows little or no ten- A ., , , . , ., ... . 

. Author s case of lupus of the cartilaginous 

dency to spread. There is no lupous portion of the septum. 

lesion of the skin. 

Treatment. — Spontaneous recovery may take place, though this is 
exceptional. It does not readily yield to treatment. Local escharotics, 
curettage, the galvanocautery, serumtherapy, surgical removal, and 
radiotherapy, have all been tried with varying success. 

The escharotics which have been used are lactic acid, carbolic acid, 
chromic acid, the arsenic paste, and other destructive chemical agents. 
Curettage has also been tried, usually with little result. Curettage 
followed by the local application of an escharotic affords somewhat better 
results, though even this is far from satisfactory. Local cauterization with 
the galvanocautery is a procedure often resorted to, though usually with 
negative results. Serumtherapy has been attended with some success, but 
its limited use, thus far, does not afford a sufficient basis for a fair con- 
clusion as to its efficacy. Surgical removal by excision of the diseased 
area is also as ineffectual as the measures just mentioned. Radiotherapy 
has proved of the greatest value in these cases. 

Radiotherapy. — Radiotherapy consists in the local application of heat 
and light rays endowed with biochemical energy. Generally speaking, 
20 




306 THE NOSE AND ACCESSORY SINUSES 

the blue-violet rays are the most potent, though the ultra-violet and 
arrays are also effective. The energy may be applied by the x-ray 
tube, the Finsen apparatus, the leukodescent lamp, and radium. 



LUPUS OF THE PHARYNX AND LARYNX 

Posey and Wright quote H. Myngid's report of 20 patients with 
lupus of the skin in which the larynx was affected in 10 to 20 per cent, 
of the cases. Fifteen of the cases were females and 5 were males. Hunt 
in 411 cases of external lupus found either the pharynx, larynx, or the 
nose involved in 20 per cent, of the number. In 173 cases of lupus 
of the mucous membranes in Doutrelpont's clinic, only 6 were free 
from cutaneous lesions. The nose was affected in 75 cases, the palate in 
31 cases, and the larynx in 13 cases. The lesion often appears before 
puberty. (See Lupus of the Nose for a more general discussion of lupus.) 



LUPUS OF THE AURICLE 

Lupus of the auricle manifests itself in all the forms found in other 
parts of the body, namely, hypertrophic, macular, papillary, and ulcer- 
ous, and is usually an extension from the face. 

It begins with tubercles the size of a pinhead or larger, which are 
brownish in color, and slightly scaly on their surface. They are arranged 
in groups, and are surrounded by a slight efflorescence. The skin is 
contracted around the diseased areas. The scarred appearance is due 
to the deep penetration of the tubercles. Keloid formations are quite 
common. 

The ulcerous type is rare and is characterized by ulcerations covered 
with thick crusts beneath which there is a spongy base. The edges of 
the ulcers are undermined and pale, with an occasional typical nodule. 

Treatment. — The treatment of lupus has been so uniformly suc- 
cessful under the Finsen phototherapy, the Rontgen-ray, and the leuko- 
descent light that the older methods of treatment have become almost 
obsolete. 

Hollander reports excellent results following the application of hot 
air to the diseased surfaces. The method is worthy of trial, especially 
if the Finsen, Rontgen-ray, and leukodescent light treatments are not 
available. 

If simpler methods of treatment fail, the lupous areas may be excised 
and a subsequent plastic operation performed to overcome the defor- 
mity resulting from the primary operation. Another form of treatment, 
much in vogue in Europe, is first to curette the granulating areas and 
then apply a paste, the base of which is arsenic. This mode of treat- 
ment has been much vaunted in this country by charlatans as a means 
of curing cancer, most of the cancerous cases being, however, one or 
the other types of lupus heretofore mentioned. 



TUBERCULOSIS OF THE PHARYNX AND FAUCES 307 



TUBERCULOSIS OF THE NOSE 

Tuberculous infection of the nose is characterized by either a low- 
grade, slightly depressed ulcer on the anterior portion of the septum 
or floor of the nose, or a sessile, wart-like tumor in which the tubercle 
bacilli are present. 

Tuberculous lesions of the nose may be primary or secondary to a 
similar process in the lungs. It is generally secondary, though cases 
are not rare in which the processes are limited to the nose. 

Varieties. — (a) Superficial ulceration; (6) wart-like or sessile tumors. 

The superficial ulcers are the most common. 

The wart-like growths are hyperplastic, and, like the ulcerous variety, 
bleed easily. The removal of either variety is followed by rather slow 
healing and by subsequent recurrence. 

The complications are perforation of the septum, with extension to 
the skin of the upper lip, and in extremely rare instances to the nasal 
accessory sinuses. Kyle suggests that the low resistance of the tissues 
affords a suitable? soil for all forms of microorganisms of chronic granu- 
lomata. The treatment consists in curettage and the application of 
arsenical paste. The ulcer or tumor should be anesthetized with a 5 
to 10 per cent, solution of cocaine, after which the diseased area should 
be thoroughly curetted. A light application of the arsenical paste may 
then be made to insure the destruction of remaining fragments of 
tuberculous tissue. The radiant energy of the leukodescent lamp, 
Finsen light, or some other source of radiant energy may be tried, 
although I am not informed as to their beneficial effects in this type 
of tuberculosis. 

In spite of all forms of treatment, there is a strong tendency for the 
tuberculous lesion to persist, and if it disappears, to return. 

TUBERCULOSIS OF THE PHARYNX AND THE FAUCES 

Tuberculosis of the pharynx and fauces is rare and is probably always 
secondary to pulmonary or laryngeal tuberculosis. It is usually asso- 
ciated with, and is probably an extension from, tuberculous laryngitis. 
It has no point of attack, but may begin in the soft palate, uvula, tonsils, 
lingual tonsils, or the pharyngeal mucosa. Unlike nasal tuberculosis, 
it tends to spread to adjacent parts. 

The part affected presents a worm-eaten appearance, the ulcers being 
surrounded by an area of congestion. The ulcers are superficial and 
covered with a dirty grayish secretion. They bleed easily upon probe 
pressure. There is little or no induration except at the borders of old 
chronic ulcers. When the lingual or faucial tonsils are the seat of ulcera- 
tion the depth of the ulcer is great; even the whole tonsil may be destroyed. 
Cases are reported in which the faucial tonsils were the seat of primary 
infection and infiltration. It is, perhaps, impossible to estimate the 
proportion of cases that are primary in the tonsils, though it is perhaps 



308 



THE NOSE AND ACCESSORY SINUSES 



larger than is generally supposed. In other portions of the pharynx 
and fauces it is rarely primary. The infection occurs either through 
the lymph channels or by contact of the infected sputum with the 
mucous membrane. 

Symptoms. — The symptoms vary with the anatomical location and 
extent of the lesion. If the soft palate is involved, the proper approxi- 
mation of the palatal muscles to the posterior wall of the pharynx is 
interfered with, and fluids and solid food may enter the nose upon deg- 
lutition. The same condition allows the secretions to accumulate and 
dry in this portion of the pharynx, which leads to hawking and nausea 
in'the effort to dislodge it. An infiltration of the uvula may cause pain 
and a tickling cough. As the secretions are thick and the parts often 
exceedingly painful upon movements, the secretions are often allowed to 
accumulate. The voice is muffled and hoarse, or aphonic. 

Diagnosis. — Syphilis is about the only disease with which tuberculosis 
of the pharynx may be confounded. The following tables adapted from 
Lennox Browne will aid in the diagnosis: 



Tuberculous ulcers. 

1. Superficial moth-eaten surface. 

2. Mildly red areola. 

3. Ragged, ill-defined edges. 

4. Indistinct demarcations. 

5. Grayish, ropy secretion. 

6. Scanty secretion. 



Syphilitic, ulcers. 

1. Deep red and angry surface. 

2. Angry red areola. 

3. Sharply cut edges, 

4. Distinct demarcations. 

5. Purulent yellow secretion. 

6. Profuse secretion. 



Prognosis. — The prognosis is grave. In those cases in which it is 
primary in the tonsils it is not serious. When we remember that tuber- 
culosis of the pharynx is nearly always secondary to pulmonary involve- 
ment the gravity of the disease is apparent. Kanasugi regards pharyngeal 
tuberculosis as being more grave than any other localized type, and 
the primary more than the secondary. 

Treatment. — Curettage followed by the application of pure lactic acid 
is a common form of treatment. It is doubtful if climatic or outdoor 
treatment is as effective, as the pulmonary involvement is usually well 
advanced. Forced feeding on raw eggs and milk should be a part of 
the treatment of all tuberculous diseases when there is loss of weight and 
strength. The local application of a 2 to 10 per cent, solution of formal- 
dehyde should be tried as in laryngeal tuberculosis. The pain should 
be controlled by the local application of cocaine, the administration of 
opiates, or the leukodescent light or other radiant energy. Painful 
deglutition is relieved by the application of cocaine immediately before 
meals. 

TUBERCULOSIS OF THE LARYNX 



Synonyms. — Consumption of the larynx; consumption of the throat; 
laryngeal phthisis; tuberculous laryngitis. 

Definition. — Tuberculosis of the larynx may be primary or secondary, 
and is characterized by an infiltration of the glands and connective tissue 
of the larynx. It gives rise to dysphagia, aphonia, and dyspnea. 



TUBERCULOSIS OF THE LARYNX 309 

Etiology. — The view that laryngeal tuberculosis is always secondary 
is held by almost all observers, and is proved by the findings of autopsies, 
there being very few recorded cases of death by laryngeal tuberculosis 
in which either a healed or active pulmonary involvement has not been 
found. The opponents of this view are very few in number, the most 
prominent of them being Dr. Gleitsmann, whose researches have been 
extensive, and who reports two cases of primary laryngeal and pharyngeal 
tuberculosis in his own practice which were cured. In the report of his 
cases, he quotes Demme, E. Fraenkel, Prof. Rebinski, Orth, Coghill, 
J. S. Cohen, Dehio, and Lancereaux in support of his view. 

Goodale has seen many cases of tuberculous laryngitis which he 
thought were primary, and which for a time seemed to yield to treatment ; 
but the subsequent progress of the disease always proved fatal through 
the associated pulmonary tuberculosis. It is possible in a suspected in- 
stance of tuberculous laryngitis, where the pulmonary signs are negative, 
that a radiograph may disprove or substantiate the presence of pulmonary 
tuberculosis. Demme, in 1883, reported the case of a boy, aged four 
and one-half years, who died of tuberculous meningitis; the necropsy 
showed the presence of laryngeal ulceration with tubercle bacilli, the 
thorax and abdominal organs being at the same time free of tuberculous 
disease. He says many other cases in which such a condition was sus- 
pected have also been recorded; and it may now be considered as an 
accepted fact that tuberculous disease may not only attack the larynx 
primarily, but may cause death without the lungs being affected. 

The disease is more common in men than women, and occurs especially 
between the ages of twenty and forty years. 

Knight quotes Heinze's statistics, and adds that of the laryngeal 
lesions more than one-half were ulcerative, a proportion confirmed by 
the Brompton Consumption Hospital, nearly twice as large a percentage 
as that given by many other investigators. The mode of invasion of 
the larynx is either by direct infection through the inspired air or by the 
expectorated sputum, or indirectly by conveyance of bacilli from the 
tuberculous foci in the lungs through the blood current or lymph channels, 
which is doubtless the more frequent route. If the contrary were true, 
tuberculous laryngitis would be much less rare than it is. The apparent 
immunity of the larynx against primary infection is difficult to explain. 
There is no essential difference between the mucous membrane of the 
larynx and the nose and other portions of the upper respiratory tract, 
excepting the pharynx. The mucosa of the nose is more exposed to the 
irritating influence of the atmosphere, and to trauma from picking crusts 
from the vestibule, and in this respect the abrasions offer a favorable site 
for the infection; the larynx is also subject to abrasions in the course of 
chronic laryngitis and in excessive use of the voice, but it remains to 
be proved that under these conditions it becomes the seat of primary 
tuberculosis. Shurley contends that the ventricles of the larynx afford 
a sheltered, quiet place for the development of the tubercle bacilli, and 
that in spite of this fact they do not readily develop here. The hidden 
recesses of the crypts of the tonsils also afford an ideal place for the 



310 THE NOSE AND ACCESSORY SINUSES 

growth of the bacilli, and, according to Mayo, 8 per cent, of all tonsils 
removed by him are tuberculous. Robertson's statistics support Mayo's. 
There is the necessary temperature, quiet, and protection from the 
currents of air to favor such a process. The tonsils are undoubtedly a 
common source of infection. Having gained entrance to the lymphatic 
circulation by this route, they travel downward to the lymphatic glands 
of the anterior triangle of the neck, thence to the lymphatic glands of 
bronchial tubes, and from there to the substance of the lung. I believe 
that the explanation of the apparent infrequent primary involvement 
of the larynx is to be found in inherent resistance of all mucous mem- 
branes to the invasion of the tuberculous germs, and that the exceptions 
to the rule are in the nasal mucous membrane of the anterior portion of 
the cartilaginous septum, and the mucosa of the tonsil crypts, where 
the abrasions are so often present, and where the conditions are excep- 
tionally favorable for the growth of the bacilli. The site for the tuber- 
culous infection of the nose is at the point where it is or may be daily 
denuded of its epithelial covering, and where the deposit of tubercle 
bacilli is abundant. It would be strange, indeed, if tuberculous infection 
did not occur under these circumstances. The tonsillar crypts form 
ideal sites for the growth of the bacilli, being warm, practically without 
motion, and plugged with secretion, food, and desquamated epithelium. 
In these hidden recesses the bacilli flourish and remain constantly in 
contact with the mucous membrane. The crypts are also the site of 
frequent inflammations, during which the epithelium may be impaired, 
thus affording a favorable condition for the invasion of the tubercle bacilli 
into deeper lymphatic tissue. Indeed, during inflammations the inter- 
cellular spaces become larger and permit the bacilli to pass through. 
It is more than probable that when the bacilli are indefinitely lodged on 
a mucous membrane they may penetrate through these spaces without 
an abrasion being present. The favorable conditions existing in the 
nose and tonsils are not present in the larynx, hence the tubercle bacilli 
rarely primarily infect the larynx. When, however, pulmonary tuber- 
culosis is established, and the expectorated sputum constantly bathes 
the laryngeal mucous membrane, the conditions for infection are much 
more favorable. The constant presence of the bacilli, the mechanical 
irritation, the abrasions produced by coughing, and the lowered resistance 
of the cellular structures in general combine to favor such an infection. 
It is probable, therefore, that infection is usually secondary to the pul- 
monary involvement, and not primary. 

Pathology. — The first apparent change in the larynx may be an 
ischemia of the mucous membrane. This is usually referred to as an 
"ashen-gray" color, which is said to be pathognomonic of tuberculosis. 
It is not always so, however, as it may occur in any general anemia. 
I have in several instances been enabled to make a diagnosis of tuber- 
culosis by the "ashen-gray" color before the stethoscope showed positive 
evidences of the disease in the lungs. I referred these cases back to 
their physician, with the suggestion that the tuberculin test be tried, 
and in each instance a typical reaction occurred. I contend, therefore, 



TUBERCULOSIS OF THE LARYNX 311 

that while the " ashen-gray" color is not pathognomonic of tuberculosis, 
it is, nevertheless, a valuable early sign in many cases, especially when 
there is also a pulse of 100 or more and a daily rise of temperature. It 
should be stated that the mucous membrane of the larynx is not always 
of an " ashen-gray" color in tuberculosis, but, on the contrary, it may 
be quite re'd, inflamed, and indurated. The vocal cords may be hyper- 
emic and swollen until their identity is lost in the reddened mucous 
membrane, or they may be lax, flabby, and nodular. 

The histological changes occur chiefly in the aryteno-epiglottidean 
folds, the interarytenoid space, and the epiglottis. The cartilages 
may become involved, thus giving rise to perichondritis and chondritis. 
Cicatricial contraction takes place as the healing process progresses. 
This may give rise to more or less dyspnea. 

When the arytenoid cartilage is affected the club-shaped infiltra- 
tion tumor is present (Fig. 232). When the infiltration extends to the 
aryteno-epiglottic ligament the pic- 
ture is quite characteristic of tuber- FlG 232 
culosis of the larynx. 

The epiglottis is often involved in 
the process, and when infiltrated 
presents the turban shape so often 
referred to. The infiltration may 
extend to both sides of the larynx or 
be limited to one. When both are 
affected the view of the deeper por- 
tions of the larynx is hidden. The 
tendency to ulceration is quite con- 
stant. It is rare for a well-advanced 
case of laryngeal tuberculosis to be 
free from it. The ulcers may be of 
any size within the limits of the area 
involved, and may be superficial or 

may extend to the Cartilages. They Tuberculosis of the larynx. (Author's case.) 

may be discrete or confluent, single 

or multiple, and on one or both sides. When the cartilage is involved 
by ulceration there is a purulent discharge from the mixed infection. 
Tuberculous ulcers develop more slowly than syphilitic ulcers, are 
less destructive, and are followed by less cicatricial contraction. 

Symptoms. — The symptoms of an ordinary case of laryngeal tuber- 
culosis are characteristic. As the laryngeal involvement is usually 
secondary to the pulmonary, the preceding history may afford an excel- 
lent index. There is more or less cough, often without expectoration, 
and there may be a sense of prickling or dryness in the throat. The 
voice may be hoarse or aphonic, especially when the infiltration is exten- 
sive. The dyspnea is in proportion to the degree of infiltration and the 
cicatricial contraction. Pain may or may not be present. In some cases 
it is quite severe, and local applications of cocaine and orthoform, or 
injections of morphine, are necessary to control it. In one of the author's 




312 THE NOSE AND ACCESSORY SINUSES 

cases, illustrated in Fig. 232, though the patient is aphonic, and has 
been for several years, there is no pain. Dyspnea is a constant factor, 
though not alarming in severity. During the past ten years the patient 
has gained twenty-six pounds in weight. Difficult or painful degluti- 
tion has been a more or less prominent symptom. The laryngoscopic 
examination shows the lesions described under pathology. 

Diagnosis. — Laryngeal tuberculosis must be differentiated from 
syphilis, carcinoma, and lupus. 

Syphilis of the larynx presents a "punched-out" ulcer with a yellowish 
exudate upon a dark red base. It spreads rapidly. The voice is low- 
pitched and hoarse, or raucous, but rarely aphonic. Pain is present 
upon phonation. The tuberculous ulcer is superficial and its base is 
covered with a grayish exudate. It spreads rather slowly, is painful 
upon deglutition, and the voice is weak and softly hoarse or aphonic. 

In carcinoma the base of the ulcer is raised by the crowding of the 
deeper infiltration; it is red and constantly painful, and the voice is 
continuously hoarse. 

In lupus there is usually no pain, ulceration, edema, or discharge; 
dyspnea is slight or absent, the general health good, and a lupoid lesion 
is usually present upon the skin. 

Prognosis. — The prognosis in laryngeal tuberculosis is grave, though 
not necessarily fatal. According to Harpy there were 14 spontaneous 
recoveries in 3000 cases. Under appropriate treatment the percentage of 
recoveries is increased. As a rule, however, the patient may be expected 
to live only for a comparatively short time — a few months or years. 
Death may occur from inanition, suffocation, or hemorrhage. 

Treatment. — The treatment of laryngeal tuberculosis, excepting the 
local symptoms, is the same as that of pulmonary tuberculosis. At 
present the "outdoor" treatment, especially in the earlier stages, is 
enthusiastically recommended. The buildings should be so arranged 
that the patients practically live outdoors the year round. While this 
at first thought seems impossible during the winter months, it is, never- 
theless, being done with comparative comfort. The house or tent 
affords protection from the severe cold and from the winds, while fires 
make life not only tolerable, but cheerful and comfortable. The object 
is to keep the patients in a pure circulating atmosphere as much as 
possible. The whole system is thus invigorated and the lungs are 
supplied with fresh oxygen. The vital forces are augmented and the 
reparative processes are often quickly and permanently restored. In 
mild cases, and in the incipient stage, little or no medicinal treatment 
is required, the "outdoor" treatment being quite sufficient. In well- 
advanced cases where there is great infiltration and ulceration of the 
laryngeal tissues the "outdoor" treatment is as ineffectual as any other. 

Innumerable remedies are recommended for the cure and relief of 
laryngeal tuberculosis, among them being the following: 

For the relief of cough: Codeine, | to \ grain every three hours. 
Morphine sulphate, ■£$ to -^ grain every three hours. 

For the relief of pain: Spraying the larynx with a 0.5 per cent, solu- 



TUBERCULOSIS OF THE LARYNX 313 

tion of cocaine. If there is painful deglutition, a 2 to 8 per cent, solution 
of cocaine may be applied locally, just before eating. Insufflations of 
orthoform powder may relieve the pain, is non-poisonous, and its effects 
last longer than those of cocaine. 

For curative effects, Gallagher, Levy, Lockard, and Johnson recom- 
mend local applications of formaldehyde to the larynx. Gallagher was 
one of the first to report beneficial results from this treatment. It should 
be used in solution, gradually increasing in strength from a 0.5 per cent, 
to a 10 per cent, solution. The patient may be intrusted with a 1 to 500 
solution for home treatment, but greater strengths should be applied 
by the attending physician. 

Gallagher reports excellent results with the following method of 
treatment : 

1 . Anesthesia slight. 

2. Cleanse, spray with 1 to 3 per cent, formaldehyde solution. 

3. Local application, 5 to 10 per cent, formaldehyde. 

4. R. — Orthoform 7 parts ) . &, ,. 

. . , . , . , > insufflation 

Anstol 1 part J 

5. Deep intratracheal injection of 

1$. — Menthol gr. x 

01. eucalyptus . . . . . . 5j to 3ij 

01. cinnamon gtt. j to gtt. x 

Glycerol q. s. ad gj 

The above daily. Curettage is used when deemed necessary. 

Menthol is another remedy of positive value. It may be used in 
combination with camphor and orthoform. Freudenthal uses it in 
emulsion in the following mixture: 

1$. — Menthol .............. 1 to 15 parts 

01. amyg. dulc. ............ 30 parts 

Vitelli ovarum ............. 25 parts 

Orthoform .............. 12^ parts 

Aquae des. ........... q. s. ad 100 parts 

Ft. emulsio. 

The above is injected intratracheally and often yields excellent results. 

Lactic acid has had and still has its advocates. Begin with a 10 per 
cent, solution and increase to 75 per cent., or even to full strength. It 
should only be used when there are ulcerations, or after curettement. 
It should be rubbed into the ulcerated or raw surface with a cotton- 
wound applicator at intervals of from five to ten days. The pain is 
severe and continues for four or five hours. 

Radiotherapy. — According to Gleitsmann, the Finsen light and the 

ultra-violet rays are less penetrating than the Rontgen rays, and yet the 

latter has not produced the expected results in laryngeal diseases. The 

bacilli are at first increased, and only after a prolonged use of a low 

vacuum tube is improvement noticeable. The Cooper Hewitt light, 

or mercurial waves, the search light, the actinoliffht, and the leukodes- 

. . . 

cent lamp may be used to relieve the pain, and in some instances actual 

improvement follows. It is too early to predict marked curative power 

from these sources. I have used the leukodescent lamp, but my 



314 THE NOSE AND ACCESSORY SINUSES 

experience with it is too limited to state that it does more than relieve 
the pain. The chief value of the leukodescent lamp is in the blue- 
violet rays and the radiant heat. These in combination exert a favor- 
able influence in acute catarrhal and suppurative inflammations, 
hence are of service in combating the mixed infection usually present 
in tuberculosis. The use of radium as reported by J. C. Beck relieves 
the pain just as other forms of radiant rays do. The direct rays of 
the sun, if concentrated, act in much the same way. 

Curettage should be limited to the ulcerated areas, while the parts 
which are simply infiltrated and have an unbroken surface should be 
carefully avoided. It has been conclusively shown that the infiltrated 
areas may remain quiescent indefinitely. When the tuberculous ulcer 
has been curetted, the sluggish process stimulated, and the overlying 
necrotic tissue removed, the local treatment given in the preceding 
paragraphs should be continued. 



TUBERCULOUS LARYNGITIS IN PREGNANT WOMEN 

Lohnberg observed 5 cases in two years. In 2 there was no evidence 
of tuberculosis elsewhere, and in the others the laryngitis was the principal 
lesion. This was true in the cases reported by Tiirck. Lohnberg has 
collected 21 similar cases from the literature. The evidence is in favor 
of the assumption that pregnancy affords a predisposition to this affection 
and whips the latent process to a gallop. Furthermore, he says that 
every pregnant woman with diffused laryngeal tuberculosis is imme- 
diately doomed, and possibly also those with only a single tubercle. 
The only treatment is the palliative use of menthol-orthoform emulsion, 
formaldehyde, etc., but these lose their efficacy after a time, and relief 
is only obtained from morphine and tablets of cocaine. 

Pregnant women should be carefully examined on the slightest sus- 
picion of trouble in the throat, and should be placed upon the treatment 
outlined above, and especially the outdoor treatment. Every woman 
affected with tuberculosis should be warned that the tuberculous process 
may be aggravated by pregnancy. It therefore follows that an unmarried 
woman suffering from tuberculosis should not marry until a cure has 
been effected. 



TUBERCULOSIS OF THE MIDDLE EAR AND MASTOID PROCESS 

Tuberculosis of the middle ear may be primary or secondary. A. W. 
Milligan believes the primary form, especially in young children, is 
more common than is generally supposed. Secondary tuberculosis of 
the middle ear is usually a complication of a tuberculous process in some 
other part of the upper respiratory tract, rather than a complication of a 
similar disease of the bones, glands, or abdominal viscera. In a series of 
cases reported some years ago, Milligan found 16 per cent, of all adenoid 



TUBERCULOSIS OF MIDDLE EAR AND MASTOID PROCESS 315 

cases to be tuberculous. This is a possible explanation of the frequent 
involvement of the middle ear. 

Symptoms. — The symptoms of tuberculosis of the middle ear vary 
with the acuity, intensity, or the chronicity of the process; also with a 
simple or a mixed infection. 

The acute variety is characterized by some redness of the drum 
membrane, slight pain, and multiple perforation. The hearing is con- 
siderably impaired. The facial nerve may be paralyzed, if the infection 
becomes mixed, the nature of the disease is obscured by the greater 
intensity and destructive character of the inflammatory process. 

Diagnosis. — The chronic variety, which is the usual form, is readily 
diagnosticated, as it runs a slow course and is characterized by little 
impairment of hearing (though this is variable), tinnitus, a sense of 
fulness in the affected ear or ears, and an almost or quite complete 
absence of pain. In the early stage there are multiple perforations, 
each of which is the site of a tubercle which has broken down. Later 
these coalesce and form larger perforations, which often result in a 
complete destruction of the membrana tympani. 

To confirm the diagnosis, the secretions and the granulation tissue 
should be examined for the tubercle bacilli and giant cells. Should they 
not be found, a guinea-pig should be inoculated with some of the tissue, 
and at the end of five to eight weeks examined for the results of the test. 
In one of my cases the microscopic findings were negative, but the 
inoculation experiment was positive. Climatic treatment in Colorado 
and permanent residence there resulted in an apparent cure. 

Milligan draws the following conclusions: 

(a) A final and exact diagnosis is imperative both from the point of 
view of prognosis and of treatment. 

(b) The disease is most frequently found as secondary to a tuberculous 
process in other regions of the body. 

(c) Primary tuberculous disease of the middle ear is probably of more 
frequent occurrence than is usually supposed. 

(d) The prognosis is always grave, but in a certain proportion of cases 
suitably planned surgical intervention will eradicate the disease. 

(e) In many cases it is advisable to conduct the treatment in stages. 
(/) When less than 10 per cent, of the hearing power remains no 

attempts should be made to preserve the ear as an organ of sense. 

(g) When more than 10 per cent, of the hearing power remains in a 
patient otherwise in apparent health, a definite attempt should be made 
to preserve the remaining hearing power. 

(k) When the tuberculous origin of the ear disease has been scien- 
tifically demonstrated, the case should be regarded as infectious, and 
precautions taken accordingly. 

Robert Levy, who has had exceptional opportunities to study middle- 
ear diseases in tuberculous patients in Colorado, summarizes as 
follows : 

Any of the usual affections may affect the tuberculous as well as the 
non-tuberculous. 



316 THE NOSE AND ACCESSORY SINUSES 

The usual modifications of an acute otitis in a tuberculous subject 
are manifested in the course of the disease. 

It is doubtful whether the Bacillus tuberculosis is present as a dis- 
tinctly etiological factor or as an accident. 

Clinical tuberculous otitis occurs with moderate frequency in Colorado, 
being secondary to lesions of the respiratory organs. 

Tuberculous otitis may develop when the general symptoms of tuber- 
culosis have been arrested and the patient's condition is unusually good. 

Tubercle bacilli may find their way into the middle ear through the 
Eustachian tube, the lymph channels, and the blood current. 

Unusual care must be exercised in the application of the nasal douche 
in tuberculous patients. The discharge may be temporarily arrested. 

It must be exceedingly rare for miliary tuberculosis to develop from an 
otitis as the focus of infection. 

Serumtherapy is apparently of some, though uncertain value. 

Prognosis. — Generally speaking the prognosis is unfavorable. There 
are, however, numerous exceptions to the rule. 

Unfavorable. — (a) It is especially unfavorable in acute cases. 

(b) Rapid destruction of bony tissue of the labyrinth and mastoid 
process is another unfavorable sign. 

(c) Mixed infection adds to the destructive nature of the process. 

(d) Well-advanced pulmonary tuberculosis renders the prognosis 
unfavorable. 

(e) Marked general debility from any cause is an unfavorable sign. 
More Favorable. — (a) In children the disease is often local or secondary 

to diseased tonsils and cervical glands. The removal of the tonsils and 
glands, and the diseased centre in the mastoid process is usually followed 
by complete recovery. 

(b) In adults otherwise healthy the prognosis under simple treatment 
is good. 

Treatment. — General and climatic treatment must be conscientiously 
carried out. 

Goldstein reports four cases which he considers primary tuberculous 
infections. All of these cases, he says, were seen more than three years 
previous to his report; three are still living, and careful physical examina- 
tion fails to show any tuberculous infection. There were no evidences 
in the histories of these cases or in their clinical development either of an 
acquired or hereditary tuberculosis. Of the four cases, three involved 
the mastoid cells extensively and showed an unusually active and rapid 
invasion. All of the cases developed from a preexisting otitis media 
suppurativa "chronica, and appeared to him as direct infection by the 
Bacillus tuberculosis. In the three cases in which the mastoid operation 
was performed the wounds healed by firm granulations, and all evidence 
of tuberculosis ceased with the removal of the local process. This 
is in direct contrast to the healing of wounds in patients in whom the 
systemic tuberculous invasion is present. The data which has been 
furnished in the cases herein reported point to a definitely localized 
specific infection of the cavum tympani and mastoid cells, with the 



SYPHILIS OF THE XOSE, PHARYNX, FAUCES, AND TONSILS 317 

characteristic development of a tuberculous process as it occurs in bone 
tissue, and with the definite demonstration of the Bacillus tuberculosis 
in one case. 

The treatment should be selected with reference to the type of mani- 
festation, the age, and general health of the patient. 

(a) In primary tuberculosis of the mastoid process, good results may 
be obtained by the mastoid operation, especially in children. In children 
it may be necessary to remove the tonsils and cervical glands, as failure 
to do so subjects the patient to the chance of a return of the process. 

(b) When the pulmonary tuberculosis is not advanced, the mastoid 
operation is indicated, and may be followed by very satisfactory results. 
These cases also do well in a suitably selected climate or in tent colonies, 
with adequate nourishment and with local treatment. The tuberculin 
treatment is of value if Koch's new tuberculin is given under opsonic 
control. 

(c) When the pulmonary tuberculosis is well advanced, operative 
treatment is useless. Even in the more favorable cases, the operation may 
be followed by only temporary improvement. If the patient is greatly 
debilitated from any cause, operative treatment is contra-indicated. 
In such cases the necrotic process usually continues, and the bony walls 
remain denuded and covered with pus. 

(d) When there is mastoid swelling or redness an early operation for 
the relief of the abscess is indicated, regardless of the general character 
of the disease. 

(e) Climatic or open-air treatment and reconstructive remedies should 
be used in those cases in which there is little or no involvement of the 
lungs; outdoor air in a cloudy climate is recommended. 

O. J. Stein recommends the use of formaldehyde, a few minims of 
which are dropped on a gauze dressing which is placed in the meatus 
and auricle. This should be covered with a thin layer of cotton and 
sealed with collodion to prevent external evaporation. The fumes of 
the formaldehyde penetrate to the diseased area and exert a favorable 
influence upon it. (See Treatment of Laryngeal Tuberculosis.) 



SYPHILIS OF THE NOSE, PHARYNX, FAUCES, AND TONSILS 

The fauces and pharynx are second only to the skin as sites for the 
manifestation of constitutional syphilis, particularly in the secondary 
stage. This may be accounted for in part by the presence of a large 
number of lymphoid glands, the excessive friction, and the complex 
embryological union of tissues in this region. 

Congenital syphilis is more common in the pharynx than in the nose. 
In the cases shown in Figs. 233 and 234, the pharynx and nose were 
involved. John Mackenzie says that 50 per cent, of the congenital cases 
develop in the first year of life, 33^ per cent, within the first six months. 

Primary lesion of the pharynx and tonsils is second in frequency to 
that of the genitalia, owing to the number of syphilitic nurses and sexual 



318 THE XOSE AXD ACCESSORY SINUSES 

perverts, and to the use of unsterilized surgical instruments in office prac- 
tice. In one of my cases the primary lesion occurred on the left tonsil, 
which was incised for quinsy by a practitioner who was syphilitic. 

When I first saw the patient there was an ugly superficial ulcer with 
indurated edges on the upper portion of the tonsil. Within a few days 
the typical secondary rash appeared, thus confirming the diagnosis. 

Females are more often affected than males, and one or both tonsils 
may be the seat of the primary lesion. 

The primary lesion is usually of short duration, though when it occurs 
on the tonsils the inflammation may be so great as to extend the period of 
ulceration to the second stage. This has been true in some of my cases. 

Fig. 233 Fig. 234 





Syphilitic scars of the fauces and pharynx causing Author's case of congenital syphilis of 

a partial constriction of the isthmus between the the nose, 

epipharynx and mesopharynx. (Author's case.) 

The secondary lesion consists of the usual erythema of the face and 
body and mucous membranes. It may appear from six to eight weeks 
after the initial lesion or even as late as several months. The erythem- 
atous patches in the throat have been described as ulcerations, though 
Lennox Browne claimed that they are not true ulcers, but simple 
abrasions of the surface epithelium. 

The tertiary lesions appear from three to twenty-five years after the 
primary manifestation, and may be ulcerative, gangrenous, or gumma- 
tous, and very destructive to both soft and bony tissues. 

Symptoms. — The symptoms of the primary stage are ulcers with 
indurated edges, which cause pain in the ear if the arch of the fauces is 
affected. If the inflammation extends to the pharyngeal orifice of the 



SYPHILIS OF THE LARYNX 319 

Eustachian tube there is some deafness and tinnitus. The lymphatic 
glands of the neck are usually enlarged. 

In the secondary stage there may be cough or a tickling sensation 
in the throat. In some cases pain or a dull aching is complained of. 
Dysphagia and a pseudomembranous angina, accompanied by a slight 
elevation of temperature, may be present. There may also be erythema- 
tous patches on the skin and in the throat, those in the throat often being 
mistaken for superficial ulcerations. Upon close examination they are 
found to be mere abrasions or elevations of the superficial epithelium. 

In the tertiary stage the odor is characteristic, and is known as syphilitic 
ozena. There is some pain, but it is not as severe as the lesion seems 
to warrant. The pain is increased upon deglutition. 



SYPHILIS OF THE LARYNX 

The primary, secondary, and tertiary manifestations of syphilis may 
appear in the larynx, though the primary lesion is extremely rare. Syphilis 
of the larynx is estimated as comprising from 1 to 15 per cent, of all cases 
of syphilis. Its occurrence in the pharynx is given as about 10 per cent., 
and in the nose as nearly 3 per cent, of all cases. About one-fifth of all 
the cases of syphilis appear, therefore, to affect some portion of the 
upper respiratory tract. 

Syphilis of the larynx occurs most frequently between the twentieth 
and fiftieth years of life. In the congenital form it appears either in the 
first few months of life or at about the age of puberty. When it occurs 
soon after birth the lesions are usually secondary. If the second stage is 
completed in utero the disease may only become manifest in the third 
stage after the lapse of several (usually from two to fifteen) years. 

Secondary erythema of the larynx usually occurs as an accompani- 
ment of the same process in the pharynx, but whether hereditary or 
acquired it is in the tertiary stage that relief is usually sought. Males 
are more often affected than females. 

Gross Pathology. — The lesion is usually bilateral and appears upon 
the true and false cords as a catarrhal inflammation with hyperemic 
spots and abraded epithelial areas. Condylomata may occur on the 
epiglottis or upon the laryngeal mucous membrane, and cause consider- 
able stenosis. 

Symptoms. — Though the ulceration takes place very rapidly, the pain 
is usually slight. The lesion first appears in the form of a clear-cut, deep 
ulcer. Induration is not always present, though there may be slight 
thickening at the edges of the ulcer. Edema is not a marked feature. At 
the bottom of the ulcer the cartilage may be necrosed and may be the seat 
of suppuration; that is, perichondritis and chondritis of the laryngeal 
cartilages may be present. The mucous membrane is hyperemic and 
darkly congested. The condition is improved by the administration of 
the iodides, though this may be temporary. Hemorrhages sometimes 
occur, and in rare instances endanger life. 



320 THE NOSE AND ACCESSORY SINUSES 

The vocal changes are unilateral paralysis (though it may be bilateral), 
with a raucous hoarseness or aphonia. Cough is in some subjects an 
early symptom. Dysphagia may or may not be present. If the syphilitic 
lesion is located on the posterior aspect adjacent to the mouth of the 
esophagus of the larynx, dysphagia is usually a marked symptom. 

Prognosis. — Syphilis of the larynx usually yields to treatment, though 
it may leave the vocal apparatus somewhat impaired as to its anatomical 
and physiological integrity. Life is not usually in any great danger, 
except in those cases in which the hemorrhage is unusually severe, 
or in which the stenosis causes suffocation. When on account of the 
suffocation it becomes necessary to perform tracheotomy, the patient 
should be warned that in all probability he will have to wear a tracheal 
tube the balance of his life. 

Treatment. — The general treatment should be as for syphilis elsewhere 
in the body. Local treatment to relieve the cough or pain may become 
necessary. In case perichondritis and necrosis of the laryngeal carti- 
lages is present, it is best to first administer the iodides in full doses, in 
order to diminish the acute pathological process, and then, if necessary, 
to remove the fragments of diseased cartilage. This may be done by 
direct laryngoscopy, or by laryngofissure (see Laryngoscopy and Laryngo- 
fissure); the former is preferable, for if the other method is adopted, 
it may become necessary to repeat the operation a number of times. 

In cases of extreme stenosis, tracheotomy should be performed and a 
tracheal cannula introduced. 



SYPHILIS OF THE EXTERNAL EAR 

Primary chancre of the external ear is so rare that less than half a 
dozen cases have been reported in the literature. 

The secondary manifestations may be papular, pustular, macular, 
ulcerous, or condylomatous. The entire auricle may be destroyed by 
extensive ulcerations, or it may be greatly deformed. The manifestations 
in the ear are usually secondary to a similar affection of the adjacent skin. 

Condyloma of the meatus is rare; it occurs in the proportion of about 
1 to every 240 cases of general syphilis (Depres and Buck). 

The course of condyloma in the external meatus is as follows: 

(a) In the beginning there is a red efflorescence of the skin, other 
symptoms being absent. 

(b) A little later, diffuse swelling of the walls of the meatus occurs. 

(c) The skin begins to be slightly broken and secretion is thrown upon 
the surface. 

(d) Finally, warty growths, of a grayish-red color, form in the cartil- 
aginous portion of the auditory meatus, and, more rarely, in the osseous 
portion. They may be large enough to block the meatus. 

(e) Pain usually develops with the appearance of the condyloma, 
especially if the skin is ulcerated. It is intensified by movements of 
the lower jaw, as the glenoid fossa is in very close relation to the antero- 



LEPROSY 321 

inferior wall of the meatus. Deafness and tinnitus develop in propor- 
tion to the degree of the meatal obstruction. Fever is exceptional. 

(/) Resolution may take place either with extensive destruction of 
the tissue or with little or no changes whatsoever. In some cases the 
ulceration continues for many months. Under general treatment resolu- 
tion takes place quickly, and little or no scar tissue forms. Stricture of 
the meatus is rare. 

Diagnosis. — The diagnosis should be based upon the history of specific 
disease elsewhere in the body, the characteristic glandular swelling, 
and the appearance of the local lesion. 

Prognosis. — The prognosis of condyloma and the other secondary 
forms of syphilitic manifestation is favorable under the internal admin- 
istration of mercury and iodides. 

Gummatous formations of the external ear are usually simultaneous 
in their appearance with the same process in the middle ear. They may 
appear later as deep ulcers with elevated margins. 

Treatment. — The local treatment of the primary chancre should 
consist in cleansing the parts with black wash and then applying the 
following ointment: 

1^. — Unguent, hydrargyri, 

Lanolin aa 3iv — M. 

Sig. — To be applied with cotton pads held in place with a light bandage. 

Mercury should also be given internally, or it may be rubbed into 
the skin in the form of blue ointment. 

Condylomata and other secondary syphilitic manifestations should 
be treated by the internal administration of mercury and the local appli- 
cation of a powder composed of equal parts of calomel and the oxide 
of zinc, which should be applied once or twice daily. 

To reduce the exuberant granulations, apply a strong solution of the 
nitrate of silver. 

Gumma should be treated by the internal administration of mercury 
and the iodide of potash or iodonucleoid to the point of toleration. 



LEPROSY 

Synonyms. — Elephantiasis grsecorum; leontiasis; satyriasis; French, 
la petae; German, der Aussatz; Norwegian, spedalskhed. 

Leprosy is a chronic infectious disease caused by the Bacillus leprae. 
It is characterized by the presence of tuberculous nodules in the skin and 
mucous membranes (tuberculous leprosy), or by changes in the nerves 
(anesthetic leprosy). At first these forms may be separate, but ulti- 
mately they exist in combination. In the characteristic tuberculous 
form there are disturbances of sensation. 

It is customary to divide leprosy into two general forms, the tuber- 
culous and the anesthetic, lepra tuberosa or tuberculous leprosy, and 
lepra anesthetica seu nervosa. It is also sometimes subdivided into: 
21 



322 THE NOSE AND ACCESSORY SINUSES 

(a) Tuberculous nodular. 

(b) Non-tuberculous. 

(c) Mixed tuberculous. 

Etiology. — Geography. — In Europe it is most common in Norway, the 
Swedish, Finnish, and Russian Coasts, the East sea; then in Asia, India, 
China, Africa, Egypt, Abyssinia, Morocco; and in America (California 
and Mexico). It is also found in Australia and the Sandwich Islands. 

The Bacillus lepras was discovered by Hansen, of Bergen, in 1871, 
and is universally recognized as the cause of the disease. 

Modes of Infection. — There are three possible modes of infection, viz. : 

(a) Inoculation, — It has not been proved that leprosy is contracted by 
accidental inoculation, though it is highly probable. 

(b) Heredity. — For years it was thought to be transmitted, though it is 
probably not. 

(c) By Contagion. — The disease is contagious. The bacilli are given 
off from the nasal secretions, open sores, and the excretions of the body. 
Osier says it is probable that the bacilli may enter the body in many 
ways through the mucous membranes and through the skin. Sticker 
believes that the initial lesion is the ulcer upon the cartilaginous part 
of the nasal septum. If this is true the disease assumes greater impor- 
tance to the" rhinologist and suggests the advisability of maintaining 
thorough cleanliness of the nose on the part of those associated with 
leprous patients. 

Pathology. — The Bacillus leprae has many points of resemblance to 
the tubercle bacillus, but can be readily differentiated from it. It is 
cultivated with extreme difficulty, and, in fact, there is some doubt as 
to whether it is capable of growth on artificial media (Osier). Lepra 
tuberosa, or tuberculous leprosy, attacks chiefly the integument and the 
mucous membrane of the nose, palate, roof of the mouth, larynx, and 
pharynx. On the skin the first changes show themselves in the form of 
infiltrations; the skin in one or more places over areas of several centi- 
meters becomes elevated and assumes a brownish-red or dull red color. 
In the region of the infiltration the sensibility disappears, partly or 
completely, and on hairy parts the hair of the affected area falls out. 
On mucous membranes the lesions show themselves either as small 
patches or tubercles, or as round, flat infiltrations, which become ulcerated 
and heal with cicatricial contraction. The results are often conspicuous 
disturbances of the affected part, the disappearance of the cartilaginous 
nasal septum, the soft palate, and the epiglottis. Stenosis of the larynx 
is one of the most common occurrences. Characteristic tubercles also 
often develop on the conjunctiva bulbi, especially at the corneal bor- 
ders. The disease has a remarkably regular and progressive course, 
inasmuch as new lesions are always appearing. The outbreaks arise 
with the initial eruptions. Under febrile action, the erythematous red- 
dening of the affected parts develops, and is soon followed by the forma- 
tion of tubercles and nodules. At the site of the older lesions, usually 
at the time of the fresh outbreaks, changes take place, and miliary 
abscesses or blebs develop, either of which may end in ulceration. It 



GLANDERS 323 

is deserving of mention; that at the time of these fresh outbreaks the 
lepra bacillus may be demonstrated in the blood, in which, at other 
times, it is absent. 

Lepra Anesthetica seu Nervosa. — Anesthetic leprosy is characterized by 
sensibility and trophic disturbances of the skin and muscles. The forma- 
tion of new tissue, which produces the nodular growths of the tuber- 
culous form, is small or entirely absent. The disease begins as a leprous 
polyneuritis. Anesthetic leprosy, in typical cases, has no resemblance 
to tuberculous leprosy. It usually begins with pains in the limbs, and 
areas of hyperesthesia, or of numbness. Bullae may form very early, 
macula? appear on the trunk and extremities, and, after existing for a 
variable length of time, disappear, leaving areas of anesthesia, though 
anesthesia may develop independently of the maculae. Superficial 
nerve trunks may be large and nodular. The bullae change to destruc- 
tive ulcers. The fingers and toes are likely to contract and necrose. 
This type runs a very chronic course and may not be severe in its 
results (Osier). 

Mixed tuberculated lepra is the least common form; it constitutes 
about one-sixth of all cases, about one-half of which are apparently 
hereditary, each parent often having had a different form. It begins 
with either a tuberculous or a non-tuberculous symptom; most fre- 
quently the latter are more prominent for a few months, fever and the 
usual phenomena of tuberculization then occurring. Destruction of 
the cartilage of the nose sometimes ensues; the soft palate also may 
be destroyed by ulcerations. The balance of the symptoms are a 
compound of the other varieties. 

Prognosis. — The disease is very chronic, progressive, and probably 
incurable. The tuberculous form is destructive. The nervous form 
may not greatly impair the patient's usefulness, as in the case of the 
clergyman who continued his career for thirty years after contracting 
the disease. 

There are no specific remedies for the disease. General tonics should 
be combined with local treatment to meet the indications, and this is 
all that can be done. 

GLANDERS 

Synonyms. — Equinia maliasmus; malleus; malleus huinidus; farcy; 
morve; farcin; rotz. 

Glanders is a contagious disease affecting horses and asses. It is 
communicable to man. It is caused by the bacillus mallei. When it 
affects the mucous membrane it is called glanders, and when it affects 
the skin and lymphatic glands it is called farcy. 

Etiology. — Glanders originates in horses and asses, but is communi- 
cable to man, and from man to man. It is naturally more often found in 
men engaged in occupations which bring them in contact with beasts of 
burden. Though the bacillus may gain entrance through the follicles of 
the skin, it more often does so through an abraded or a wounded surface. 



324 THE NOSE AND ACCESSORY SINUSES 

Cases are reported of surgeons being infected while operating upon 
patients who had the disease. 

Pathology. — There are numerous closely associated nodules of low 
grade embryonal or granulation tissue, which readily break down and 
suppurate. The ulcers thus formed have undermined edges, which are 
the remnants of the wall of the preceding abscess. The process spreads 
by continuation, though later it may be carried to distant parts. It 
usually appears first in the skin, and then extends to the mucous 
membrane of the nose, though it may have its origin in the mucosa. 
Baumgarten says it is a disease which stands midway between abscess 
and tuberculosis. 

The nasal lesions are usually in the form of numerous closely grouped 
granulation nodules in the submucous tissue. There is a profuse pro- 
liferation of leukocytes and connective tissue cells, with which are 
admixed numerous bacilli of glanders. The proliferation continues until 
the pressure diminishes the nutrition of the mass, especially at its centre, 
liquefaction necrosis then ensues and the nodules become abscesses. The 
outer wall soon breaks down and the contents are discharged into the 
nasal cavities. The abscesses are thus converted into open ulcers with 
undermined edges. Cross-sections of the masses before breaking down 
show them to be composed almost entirely of leukocytes, connective- 
tissue cells, and fibrous tissue. Many Bacilli mallei are embedded 
in the masses of proliferated cells. In the acute form there are numerous 
multinuclear leukocytes in the adjoining tissue. In the chronic form 
the bone and deeper structures may be destroyed. Gangrene of the 
softer tissues may occur. 

Symptoms. — In the acute form the period of incubation is from three 
to four days. The acute symptoms often simulate rheumatism or typhoid 
fever in its initial stage. A little later the nodules appear either upon 
the skin or the nasal mucosa, according to the point of infection. They 
rapidly increase in size, as described under pathology, until (in nasal 
glanders) the purulent contents empty into the nose. The upper air 
passages are not often involved primarily in man. The progress of 
the disea-se is rapid, and usually leads to a fatal issue in a few days, 
or in two or three weeks. 

The chronic form is fatal in about 50 per cent, of the cases after two 
months to two years. This type bears a close resemblance to syphilis 
and tuberculosis. The lymph glands of the neck are often much enlarged 
in the acute form. Chronic glanders often presents the symptoms of a 
persistent coryza. The diagnosis is difficult. It may be necessary to 
inoculate a male guinea-pig with the nasal secretions to determine the 
diagnosis. At the end of two days, in a positive case, the testicles of 
the pig are swollen and the skin of the scrotum reddened. The testicles 
continue to increase in size and finally suppurate. After two or three 
weeks death occurs, and the postmortem reveals nodules in the viscera. 
The use of "mallein" is highly recommended for diagnostic purposes. 
It is used in the same manner as the tuberculin test in tuberculosis. 
In all suspected cases remove a piece of the tissue and examine sections 



ACTINOMYCOSIS OF THE NOSE 325 

with the microscope; make agar cultures and inject them into the peri- 
toneal cavity of a guinea-pig, and watch the reactions. Also use injec- 
tions of mallein, and watch the results. Above all, study the clinical 
phenomena, and from all the evidence obtainable arrive at a diagnosis. 

Prognosis. — The prognosis in the acute form is grave, for nearly all 
cases die in a few days. In the chronic form the mortality is about 50 
per cent., and death occurs in from two months to one or more years. 

Treatment. — In acute cases there is little hope of recovery. If seen 
early the tissue around the point of original infection should be either 
extensively cauterized or removed en masse. The wound thus created 
should be frequently bathed in a solution of the chloride of zinc (one to 
eight). All animals and horses suspected of being infected should be 
killed and their bodies burned. In chronic cases, tonics and the iodide 
of potash should be given, though no specific remedies are known. 

Glanders of the pharynx is usually an extension of the same process 
from the nose, though it may be primary in the pharynx. Nodules 
form here, as in the nose, and are attended by about the same general 
symptoms. The cervical and sublingual glands are early involved, 
break down, suppurate, and discharge externally. 

The chronic form is not attended with the same distinct phenomena, 
and is often mistaken for granular pharyngitis. The nodules are mis- 
taken for the lymphoid masses which occur in chronic follicular pharyn- 
gitis, though, if watched long enough, they will be seen to grow gradually 
larger and larger, until serious mechanical obstruction results. Such a 
process in the pharynx should arouse a suspicion of glanders, and the 
mallein test, or guinea-pig experiment as given under Symptoms should 
be made. 

Glanders of the larynx is rare, and when present is associated with 
the same process higher up in the respiratory tract. 



ACTINOMYCOSIS OF THE NOSE 

Synonyms. — Lumpy jaw; holdfast, or wooden tongue. 

Definition. — Actinomycosis is a parasitic, infectious, and incurable 
disease which was first observed in cattle and later in man. It is charac- 
terized by the manifestations of chronic inflammation, with or without 
suppuration. It often results in the formation of granulation tumors, 
especially about the jaw and neck. 

Etiology. — The exciting cause is the ray fungus of actinomyces. 
The predisposing causes are an abraded mucous surface, or a diseased 
membrane. The infectious material may be carried by water or food, 
and by straws, chaff, grain, needles, etc. The fungus probably grows 
upon wheat and oats, hence farmers should be cautioned against chewing 
wheat and oat straws, as they seem to be a prolific source of infection. 
Shoemakers occasionally contract the disease from the habit of holding 
a needle or awl in the mouth. Kissing may be the means of transmis- 
sion from one person to another. It occurs chiefly in young adults. 



326 THE NOSE AND ACCESSORY SINUSES 

Pathology. — The aetinomyces were formerly thought to be mould 
fungi, but Bostroem, in 1885, proved by cultivation that they are a 
variety of cladothrix, belonging to the sehizomyeetes. The diseased 
mass is made up of granulation tissue, which, except for the ray fungus, 
would be mistaken for round-cell sarcoma. Epithelioid elements and 
giant cells are sometimes present. In the granular mass, or in the 
pus, the fungus itself appears in the form of small, yellow, brown, or 
green masses, about the size of a pinhead, which, upon microscopic 
examination, are found to be composed of a central interwoven mass 
of threads, from which radiate club-shaped ended rays. In man the 
clubbed bodies are frequently absent (Senn). The histological lesions 
are alike in the actinomycotic nodule, and in the tuberculous follicle, 
only the germ body differs. Water, or a weak solution of sodium chlo- 
ride, causes the rays to swell enormously and lose their shape; ether and 
chloroform have no action upon them. The gross pathological anatomy 
of the disease is everywhere associated with chronic indurations, with 
softening and liquefaction, and with resulting sinuses and cysts. The 
head, neck, and especially the jaw, and the cervical fascia are the sites of 
the disease. In the cervical fascia the disease gives the neck a brawny 
hardness. The lymphatic glands are not, as a rule, extensively involved. 
In the ox the tongue is often affected. 

The lesion may be self-limited, as in tuberculosis, by cicatricial 
envelopment. 

The kernel-like nodules are usually multiple. They may coalesce, 
and the resulting masses mav "heal out." When bone tissue is affected, 
the destruction is central, while peripherally there is hyperplasia. 



ACTINOMYCOSIS OF THE PHARYNX AND TONSILS 

Symptoms. — The symptoms vary according to the part involved. The 
affection is chronic, but occasionally runs a rapid course. The granula- 
tion tissue is abundant and the mass resembles a tumor. Previous to 
suppuration it is quite firm, and if progressing rapidly it is surrounded by 
diffuse edema. Pain and tenderness are rarely present. When suppura- 
tion occurs the mass increases rapidly in size. 

The frequency of occurrence in different parts of the body in 500 cases, 
as collected by Poucet and Berard, is as follows: Head and lungs, 55 per 
cent. ; thorax and lungs, 20 per cent. ; abdomen, 20 per cent. ; other parts, 
5 per cent. In France the face and neck were affected in 85 per cent, of 
the 66 cases reported. 

The symptoms may be grouped in two classes: (a) Those referable to 
local tumefaction and purulent discharge, and (b) those referable to the 
general intoxication of the system by the suppurative products, or their 
metastatic spread, and which do not differ from those of chronic sup- 
puration. The local symptoms are of slow development, and are largely 
those of gradual mechanical interference of the pharyngeal function. At 
the site, or sites, of inoculation a small rounded and reddish elevation 



ACTINOMYCOSIS OF THE PHARYNX AND TONSILS 327 

appears, and is accompanied by the usual subjective annoyances of 
an attending pharyngitis. The adjacent tissues become swollen and 
tumefied, and the evidences of an acute inflammation soon change to the 
more permanent engorgement and solidity of a chronic condition. The 
swelling is irregular, but well outlined, firm to probe palpation, and 
not oversensitive, but slowly increases in size. Suppuration and the 
formation of angry-looking sinuses follow, from which issue a puru- 
lent discharge, in which are the small yellowish pellets, or masses, com- 
posed largely of the typical ray fungus. The discharge is persistent, 
and the sinuses extend deeply and produce extensive destruction of 
tissue. The spread of the process does not, as a rule, occur, and it shows 
a tendency, if it occurs elsewhere, to do so as an isolated swelling rather 
than as a connected overgrowth from the original pharyngeal focus. 
Pain is a variable quantity, and depends largely upon the seat and extent 
of the peculiar swelling. Usually there is a more or less continuous, 
heavy ache which is felt locally, and this may, at times, be eased or 
intensified into acute distress. Fetor of the breath and gastric disturb- 
ances from the purulent discharge are often present. The appearance 
of the disease elsewhere by metastasis is to be expected, especially in the 
lungs or the alimentary tract, though no portion of the body is free from 
possible invasion. The systemic symptoms may be severe or slight, 
according to the degree of involvement and the exit of the suppurative 
products, and do not differ in their character from those usually observed 
in any other suppurative condition. Death occurs from slow exhaustion 
or through some intercurrent affection or complication (Kyle). 
Diagnosis. — Actinomycosis should be differentiated from: 

(a) Sarcoma. 

(b) Tuberculous infection. 

(c) Carcinoma (of the tongue). 

(d) Syphilis. 

(e) Epulis (in jaw). 
(/) Lupus. 

It is, perhaps, impossible to make a positive clinical diagnosis of 
actinomycosis. A microscopic examination showing the ray fungus, 
or inoculation of a guinea-pig, may be necessary to establish it. The 
presence of the yellowish particles in the purulent discharge is quite 
characteristic, though not conclusive. Actinomycosis is probably not 
as rare as is generally supposed, as it is sometimes mistakenly diagnos- 
ticated as sarcoma, carcinoma, osteomyelitis, syphilis, etc. 

(a) Sarcoma is histologically quite similar to actinomycosis. A careful 
microscopic examination will, however, in actinomycosis show the 
presence of the ray fungus and some giant cells. Sarcoma does not 
break down and suppurate so early. Both occur quite frequently in 
the young. 

(b) Tuberculous disease is attended by an enlargement of the regional 
lymphatics. In actinomycosis the regional glands are not enlarged. 
An examination of the sputum or the inoculation of a guinea-pig will 
show the tubercle bacilli if present. 



328 THE NOSE AND ACCESSORY SINUSES 

(c) Carcinoma of the tongue is usually found near the base, whereas 
actinomycosis affects the tip. Then, too, in carcinoma there are lancin- 
ating pains, ulceration, and cachexia. 

(d) Syphilis, in the gummatous stage, is more amenable to treatment 
by means of the iodides. The general history of the case is also an aid 
in the differential diagnosis. Acute progressive actinomycosis may very 
strikingly resemble acute phlegmonous inflammation and osteomyelitis. 

Treatment. — The iodides are efficacious in recent cases. In old cases 
in which there is a mixed infection they are less efficient. The remedy 
should be given until marked iodism results. The injection of a 5 per cent, 
solution of the permanganate of potash into the cysts, when present, has 
produced good results. Cauterization of the skin and soft parts with the 
solid stick of silver nitrate is a valuable aid in those cases in which there 
is a fistula and suppuration. Gautier reports excellent results from the 
injection of a 10 per cent, solution of the iodide of potash into the mass. 
Electric needles may be inserted in the tumor, and 50 milliamperes of 
current passed through it. Every minute a few drops of the iodide of 
potash solution should be injected until a total of 20 minims is used. 
The electric current decomposes the iodide solution into nascent iodine 
and potash. The chemicals thus liberated in the actinomycotic tissue 
act as a deterrent to the further progress of the disease. A general 
anesthetic should be administered for this treatment. It should be 
repeated in eight days. 

The surgical treatment of actinomycosis varies from simple incision 
to the complete removal of the entire mass. The disease is best suited 
to surgical treatment before the stage of suppuration and extension to 
the regional glands. When it has progressed thus far it is no longer 
simple actinomycosis, as it is complicated by a mixed or streptococcal 
and staphylococcal infection. A simple incision is sometimes effectual, 
as is, indeed, spontaneous rupture. Should excision be resorted to, it 
should be complete, and followed by the thermocautery, to prevent 
the spread of infection to the exposed lymph spaces. After suppuration 
is established, treat as for tuberculosis, i. e., curette and pack with 
iododorm gauze. 

The disease seems to be self-limited by the formation of a capsule of 
connective tissue and by spontaneous rupture. 

Iodide of potash or iodonucleoid are probably the most reliable internal 
remedies. 

ACTINOMYCOSIS OF THE MIDDLE EAR 

Actinomycosis of the middle ear is very rare, and the only literature 
on the subject is the clinical report of a case by Zaufal, of Prague, and a 
more extended report of the same case, with the postmortem findings, 
by J. C. Beck, of Chicago, and a second case of Mojocchi, of Italy. The 
clinical aspect of Beck's case was as follows: Carl J. was fifty-four years 
old, a farmer, always healthy, with a negative history of aural, nasal, and 
pharyngeal disease, until six months previous to the examination. At 



ACTINOMYCOSIS OF THE MIDDLE EAR 329 

that time there was a swelling back of the left ear and left side of the neck. 
The swelling, at first hard, soon softened, and was never painful. Later 
a third swelling appeared on the left side of the neck, which opened 
and discharged pus through a fistula. At this time the hearing became 
defective. The functional tests of hearing showed a negative Rinne, 
and Weber lateralizing to the left side, thus showing middle-ear disease. 
There was no secretion from the external auditory meatus, but the post- 
superior wall, at the fundus, sagged as in mastoiditis. A swelling the 
size of the palm of the hand was situated over the mastoid and the region 
posterior and inferior to it. It did not fluctuate. A smaller swelling, 
anterior to this, had a fistulous opening in the region of the tip of the 
mastoid process. Compression expelled a greenish pus, containing 
small granules. The subsequent microscopic findings showed the ray 
fungus of actinomycosis in abundance. A radical mastoid operation 
was performed, but the healing process was unsatisfactory. Five weeks 
later the patient died from an intracranial hemorrhage, due to the ulcera- 
tion of a large bloodvessel in the region of the actinomycotic process. The 
postmortem was held by Chiari, who found the muscles of the neck on 
the left side and the upper cervical vertebra infiltrated with pus contain- 
ing yellowish particles. There was no suppurative process in the cavum 
tympani. A fistulous tract was traced with a fine probe from the cavum 
tympani toward the exposed incisure mastoidea. The left sigmoid sinus 
was filled with a substance of a light yellow color, and was adherent. 
The cervical glands on the left side were enlarged, and cross-sections 
showed whitish discolorations. Sections of the tonsils and the contents 
of the lacunae were negative as to actinomycosis. The ulcerated artery 
causing the fatal hemorrhage was examined microscopically by Beck, 
who found the ray fungi in its walls. This is the first reported case 
in which the ray fungus has been found in the wall of a bloodvessel. 

The only other case of actinomycosis of the middle ear on record 
is reported by Majocchi, of Italy. In his case the primary infection 
was in the lung, and the infection of the ear probably occurred during a 
fit of coughing. 



PART II 
THE PHARYNX AND FAUCES 



CHAPTEK XVII 

DISEASES OF THE EPIPHARYNX AND BASE OF THE TONGUE 

ACUTE LACUNAR INFLAMMATION OF THE PHARYNGEAL TONSIL 

According to Felix Peltesohn, the pharyngeal tonsil consists of six 
fairly symmetrical folds separated by deep furrows running in a sagittal 
direction, which may be separated from each other like the leaves of 
a book. Posteriorly and sometimes anteriorly there is a curved fold 
connecting all of them. In the middle there is a deep fissure — the 
recessus medium — to which, in some instances, a blind canal leads, and 
which was formerly erroneously described as an independent structure, 
the bursa pharyngea, which, when infected, is known as Thornwaldt's 
disease. 

Bickel, in defining a tonsil, says it is characterized (a) by its well- 
defined shape, (6) by a diffused infiltration of lymph cells and follicles, 
and (c) by crypts or lacunas, that is, mucus pockets lined with epithelium, 
around which the lymphatic tissue is arranged. 

If we take his definition literally only the pharyngeal and faucial tonsils 
are real tonsils, as the lymphoid tissue in the other parts of the so-called 
"tonsillar ring" does not have crypts or lacunae. The faucial tonsil also 
has a distinct fibrous investing capsule. 

Symptoms. — Angina lacunaris of the pharyngeal tonsil, like that of 
the faucial tonsils, is an infectious disease. It is rarely recognized as 
such by physicians on account of its hidden location back of the post- 
nares and the soft palate. The condition may be seen, however, with a 
postnasal mirror. The crypts or lacunae are filled with a yellowish-white 
exudate, composed of epithelium, inflammatory exudate, and pus cocci. 
An inexperienced physician might easily arrive at the erroneous con- 
clusion that the spots were "ulcers;" indeed, the same error has often 
been made concerning the faucial tonsils. During the acute stage the 
pharyngeal tonsils are red and swollen. 

That the disease is infectious is shown by the clinical data — namely, 
the initial chill, the rise of temperature, the prostration, swelling of 

(331) 



332 THE PHARYNX AND FAUCES 

the spleen and cervical glands, the prolonged convalescence, and the 
presence of a great variety of infectious germs. 

The secretion is often so fluid as to ooze from the crypts and coalesce 
with that from an adjoining crypt. 

Acute lacunar inflammation of the pharyngeal tonsil does not occur 
as often as acute lacunar inflammation of the faucial tonsils. This is 
probably due, in part, to the filtrating function of the vibrissa? and moist 
mucous membrane of the nose. 

It occurs most often during the first twenty years of life, because the 
lymphoid adenoid tissue is more developed and more sensitive during 
this period of life. It has a strong tendency to recur. The nose becomes 
obstructed and there is pain upon swallowing, but it is not definitely 
located as when the faucial tonsils are diseased. The voice becomes 
nasal, or void of resonance, as in hypertrophy of adenoids. The glands 
at the angle of the jaw and in the deep cervical region are swollen and 
painful upon pressure. 

The fever is cyclical, being less severe of mornings and greater at 
night. It continues for several days and leaves the patient quite ex- 
hausted. The pharyngeal tonsils continue swollen for some time, often 
permanently after the fever subsides, and cause more or less nasal 
obstruction. 

To one not accustomed to examining the epipharynx the following 
suggestion by Peltesohn is of great value in making a diagnosis: If 
the tongue is drawn far enough forward with a tongue depressor to see 
behind the palatine arch, the salpingopharyngeal fold, the so-called 
''lateral column," may be found to be deeply reddened and studded 
with yellow follicles. This condition is characteristic of angina lacu- 
naris of the pharyngeal tonsil. As the space between the soft palate 
and the posterior pharyngeal wall is still quite wide in young people, 
the postrhinoscopic examination may be easily made. 

Patients frequently complain of a feeling of fulness and pressure in 
the ears, but do not often have active inflammation of the middle ear. 
The nasal secretions are acrid, and often cause nasolabial excoriations. 

Diagnosis. — (a) Initial infective fever, chill, and cyclical fever. 

(6) Obstructed nasal passages and non-resonant voice. 

(c) Most important of all, the red and swollen follicles of the "lateral 
column" (follicles just back of the posterior faucial pillar), from which 
a yellowish secretion is exuding. 

These signs, together with the postrhinoscopic examination, will lead 
to a correct diagnosis. 

Treatment. — Experience teaches us that during the course of the acute 
or febrile stage local applications irritate and should not be attempted; 
even gargles should not be used. The patient should be kept in bed 
until the fever abates, or a few days longer, as the prostration is severe. 
He may be given pieces of ice to hold in the mouth, as this seems to 
afford some relief. Only a light diet should be allowed. 

After complete recovery the adenoids, whether large or small, should 
be thoroughly removed, as otherwise recurrence may take place. In 



ADENOIDS 333 

adults the recurrences are characterized by the formation of crusts in 
the epipharynx. The crusts, therefore, indicate the need of an adenoid 
operation. 

ADENOIDS 

Synonyms. — Adenoid vegetations; pharyngeal adenoids; pharyngeal 
tonsils; epipharyngeal tonsils. 

Definition. — Adenoids are hypertrophied lymph glands which nor- 
mally exist in the epipharyngeal space. They are chiefly located on the 
superior and posterior walls of the epipharynx, though they may extend 
into the fossae of Rosenmuller and to the mouth of the Eustachian tubes 
(tuba auditiva Eustachii). 

The edges of the walls of the recessus medius sometimes become 
agglutinated during acute inflammatory processes, and thus convert the 
groove into a sinus, which becomes infected and continually discharges 
its secretions into the pharynx (Thornwaldt's disease). 

Etiology. — The chief cause of adenoids is the irritation and inflamma- 
tion which occur in the epipharynx during attacks of one of the exanthem- 
atous fevers. It is a well-known pathological law that the lymphatic 
structures of children become enlarged or hypertrophied in response to 
bacterial stimulation, whereas the same stimulation in adults does not 
cause lymphoid hypertrophy to a corresponding degree. 

As the exanthematous fevers occur chiefly in early childhood while 
the special susceptibility exists, it is but natural to find adenoids most 
frequently during this period of life. 

According to the statistics on this subject by McBride and Turner, 
adenoids are most frequently found between the sixth and the fifteenth 
years of life, though they may occur at any period. In children who 
were otherwise normal it has been variously estimated that they were 
present in from 1 to 9 per cent, of all cases examined. In deaf mutes 
they are present in from 50 to 73 per cent, of all cases examined. 

While it cannot be said that adenoids are hereditary, they are, never- 
theless, in many instances a family characteristic, perhaps on account 
of a similar environment and similar anatomical conformations pre- 
disposing to infection of the epipharyngeal tissues. 

Climate probably plays but a small part in the causation of adenoids, 
though it should be said that a cold, damp, changeable climate subjects 
the mucosa as well as the general system to repeated shocks, which lower 
the vitality and render the lymphoid tissue an easy prey to infection. 

Pathology. — The distribution of adenoid tissue in the epipharynx 
is chiefly on the upper and posterior walls, though it may extend to the 
fossae of Rosenmuller and to the orifices of the Eustachian tubes. Ade- 
noids are composed of lymphoid tissue enmeshed in a definite though com- 
paratively delicate reticulum of fibrous connective tissue. The essential 
pathology of adenoids consists in the hypertrophy of the lymphoid tissue 
of the epipharynx which is normally present there. 

According to McBride and Turner, the pharyngeal tonsil is a peripher- 
ally placed lymphatic gland, from which efferent ducts pass to the nearest 



334 THE PHARYNX AND FAUCES 

glands in the cervical chain. Like similar glands elsewhere, the pharyn- 
geal adenoid tissue consists of a fibrous connective-tissue framework, 
supporting masses of lymphoid cells, but owing to its peripheral position 
it differs from the more deeply placed lymphatic glands in having an 
epithelial covering upon its free surface. The supporting framework 
consists of fibrous septa passing through the substance of the gland, 
from which a very delicate connective-tissue network ramifies in all 
directions toward the surface. It carries in it the bloodvessels and the 
lymphatics, while here and there, lying in clusters in the septa, may be 
seen many mucous glands whose ducts open on the surface. In the 
meshes of the delicate network lie masses of leukocytes or lymphoid cells, 
constituting the lymphoid tissue which forms the main bulk of this tonsil. 
Groups of these cells are specially differentiated in the form of more or 
less rounded or oval-shaped areas, having centres of a pale appear- 
ance, while their margins are more darkly colored. These areas are 
the follicles or germ centres of Goodsir. Covering the free surface of 
the tonsil, and dipping down into its recesses and crypts, is a layer 
of ciliated epithelium, continuous with that lining the respiratory part of 
the interior of the nose and the adjacent mucous membrane of the epi- 
pharynx. The epithelium consists of more than one layer of cells, the 
superficial ciliated cells being columnar in type, while the deeper cells 
forming two or three layers are smaller, and rest upon a well-defined 
basement membrane. 

The Epithelium. — The normal epithelial covering undergoes a certain 
amount of variation, as might be expected when a growth of this kind, 
itself subject to variations in size, fills to a varying extent a cavity like 
the epipharynx, more or less completely surrounded by firmly resist- 
ing bony walls, and whose size is intermittently changing through the 
movements of the soft palate which constitutes its floor. The epithe- 
lium is not always of uniform thickness. While preserving its ciliated 
columnar type its thickness varies in parts, so that the lining of some 
of the crypts presents an irregular outline. In a certain number of 
the preparations examined, however, there is a marked change in 
the character of the epithelium, becoming of the stratified squamous 
variety and of a very considerable thickness. This change and thick- 
ness are not general, but are confined to certain areas on the surface of 
the hypertrophy. It is not normal to this part of the upper respira- 
tory tract, because the whole of the mucous membrane of the pharynx 
as low as the level of the lower border of the soft palate is covered with 
ciliated epithelium, and it is from within the area so covered that the 
epithelium thus altered and thickened shows that these changes occur 
among the youngest of the patients examined. With two exceptions 
at the age of twelve, all were under ten years of age, and in two cases 
where the thickening was most marked the patients were only four years 
old. On the other hand, in the sections of the growths removed from 
patients of fifteen years and upward, with one exception, no thickening 
of the epithelium was observed, so that we are naturally led to the 
conclusion that this change in the epithelium is not one necessarily 



ADENOIDS 335 

dependent upon the prolonged existence of the hypertrophy. Occurring, 
as the examination shows that it does, in the younger patients, it is more 
reasonable to conclude that it is due to pressure of the growth upon the 
walls in the smaller epipharynx of the young child. Its presence on the 
surface and in patches only and less frequently in the crypts are further 
points in favor of such a view being held. Unfortunately, we are unable 
to say whether, in those cases in which the epithelium has changed to 
the pavement type, the adenoid masses were large and more or less 
completely filled the epipharynx. Such a change in the type of the 
epithelium as noted here has been observed before, as the result of press- 
ure, and is a point of some histological interest. The pressure to which 
these growths is subject is intermittent, and is caused chiefly by the 
elevation of the soft palate in the act of deglutition, pressing the soft, 
pliant mass upward against the walls of the space, and releasing it again 
when the act is completed. 

The Fibrous and Lymphoid Tissues. — A considerable variation was 
found to exist in the relative proportion of lymphoid and fibrous tissue 
in the growths examined; and McBride and Turner endeavored, by a 
comparison of the appearances observed in patients of different ages, 
to seek some explanation of the gradual disappearance or shrinking 
which takes place in the hypertrophied adenoid tissue in course of 
time. An overgrowth of fibrous tissue around the bloodvessels forms 
by a process of perivascular sclerosis; at any rate, it is in the neigh- 
borhood of these vessels that the fibrous thickening is most evident. If 
an area be examined in which this change is taking place, some of the 
bloodvessels present a normal appearance, others again show distinct 
thickening of their walls in concentric rings, with diminution in the 
size of the lumen. One specimen showed, in a remarkable manner, 
many of the bloodvessels completely obliterated, partly owing to the 
great thickening of the walls and partly to the contraction of the 
fibrous tissue outside. Round the vessels there is fibrous tissue form- 
ation, varying both in amount and in density, according to the stage 
of development that has been reached; in this way the lymphoid 
tissue becomes gradually invaded and areas of cell are isolated by the 
process. There can be no doubt that it is by fibrous-tissue formation 
that the gradual shrinking of the adenoid mass occurs. In order to 
ascertain what relation such a process might bear to the age of the patient, 
a comparative study of the various growths was made with this end 
in view. 

From such an analysis it would appear that a development of fibrous 
tissue takes place in the substance of the adenoid hypertrophy, com- 
mencing around the bloodvessels invading the lymphoid tissue, and re- 
placing it. This process, however, is independent of the age of the patient, 
and is not one that necessarily commences at or after puberty, but may 
occur at all ages, and be even more marked in the very young child than in 
the adult. The observations of McBride and Turner coincides with that 
of M. Brindel. The practical deduction drawn from these facts is. that 
we cannot say in any given case that a growth may be satisfactorily left to 



336 THE PHARYNX AND FAUCES 

disappear per se. It may or it may not do so at some early period, but 
because a patient is approaching puberty or adult life it does not follow 
that the adenoid hypertrophy will in a short time cease to exist, As 
we have already stated, such growths do, in certain cases, disappear at 
puberty, but it is quite possible that here a purely physical, as opposed 
to a purely histological, explanation may be called to our aid. Obviously, 
in the small epipharynx of the child the growth may entirely fill the space, 
while, as adult life is approached, a free space will be left between the 
adenoid hypertrophy and the palate. In the former case, each respira- 
tion will exercise suction upon the mass, while in the latter this physical 
effect will be much diminished, if not entirely absent. 

The foregoing findings should be given wide circulation among the 
medical profession, as physicians too often advise their patients "to wait 
for puberty," as the adenoids will "shrink" at that time. "Waiting" 
for adenoids to "shrink" is always a foolish and dangerous thing. While 
waiting, the attending inflammation is ever progressing, and may and 
actually does in 66 per cent, of all cases, invade the Eustachian tubes 
and middle ear. Furthermore, it is shown that the atrophy does not 
occur after puberty any more than at a younger age; indeed, the atrophy 
is independent of the age in the patient. Why wait, therefore, for a 
process of shrinking which has no definite period of occurrence. 

Symptoms. — The symptoms of adenoids may be divided into: 

(a) Objective. 

(b) Subjective. 

(c) Collateral. 

Objective Symptoms. — The objective symptoms are those which are 
appreciated through the special senses of the attending surgeon. 

By inspection the physician notes the open mouth, thick, short upper 
lip (Plate IX), the comparatively expressionless countenance, and with 
the laryngeal mirror he finds the epipharynx more or less filled with the 
adenoid masses. 

By the sense of touch he distinguishes a gelatinous, worm-like mass in 
the epipharynx. The finger should be anointed with vaseline before it is 
introduced into the epipharynx, so as to reduce its frictional qualities 
to the minimum. Even then great care should be exercised lest the deli- 
cate mucous membrane of the epipharynx be injured. In spite of these 
precautions the finger is often streaked with blood upon its removal. I 
find the digital examination of more value in a majority of the cases 
than the one with the mirror. It need occupy but a few moments for 
its performance. 

The examining surgeon should stand in front of and to the right of 
the patient, encircling the head with his left hand and arm to steady 
it, while the index finger of his right hand is introduced into the epi- 
pharynx. ^ McBride and Turner have suggested that if the thumb of 
the examiner is just outside the patient's right cheek, he can prevent 
biting by pressing the thumb against the cheek wall. The soft tissues 
being thus forced between the patient's teeth, he will not bite the 
examiner's finger. 



PLATE IX 




An Adenoid Face. 



ADENOIDS • 337 

Faulty development of the chest .walls is also characteristic of mouth 
breathing in children. 

The sense of smell should also be utilized in the examination for 
adenoids, as a fetid breath is sometimes present. 

The auditorv sense should also be utilized in the diagnosis, as the 
patient's voice is often characteristic. The articulation is muffled and 
the resonance of the voice is diminished. 

The Subjective Symptoms.- — Restlessness during the night is a promi- 
nent symptom; the patient often throws the covers off during the uncon- 
scious •rolling and tossing which is so characteristic of mouth breathers. 
Night terrors* are also frequently complained of, especially if the child is 
troubled with enuresis. I have often noted that night terrors or horrible 
dreams immediately precede nocturnal urination. 

Night terrors are not present in all cases, perhaps not in more than one- 
third of them; they are in all probability due to reflex causes and to an 
excess of the half-way products of metabolism. These dreams are often of 
themost terrible nature, and are often indelibly impressed upon the memory. 

Daytime restlessness is also a characteristic sign of adenoids. The 
child is fretful and peevish, or is inclined to turn from one amusement 
to another, or from an imposed duty to play. 

The mental faculties are often much impaired in adenoid subjects. 
Aprosexia, or difficult attention, first described by Guye, of Amsterdam, 
is very often present. The child is listless and has difficulty in applying 
himself continuously to his play, studies, or other tasks, of which he 
soon tires. He has fits of. abstraction. I once knew of a boy in school 
who was afflicted with ideal abstraction, though he had a fairly good 
mind. In those cases, however, in which there is little obstruction, the 
mental faculties are but little affected. 

Taste and smell are sometimes impaired, which is not strange, in view 
of the fact that the sense of smell and of taste are so intimately associated, 
and the epipharynx is blocked with adenoids, thus compelling the child 
to breathe through its mouth. 

The breath is often fetid, from the decomposition of the retained secre- 
tions and from the disordered stomach which is so often complained of. 

Bilious attacks sometimes complicate the case. 

An elevation temperature is not an uncommon symptom, as the adenoid 
growth is frequently the seat of a lacunar or catarrhal inflammation. 

Epipharyngeal catarrh is an almost constant accompaniment of 
adenoids. Indeed, it is doubtful if adenoids of any considerable size 
are present without a concomitant chronic epipharyngitis, or what is 
commonly spoken of as a pharyngeal catarrh. This symptom or com- 
plication is one of the strongest arguments in favor of the removal of 
adenoids, as the catarrhal inflammation has a tendency to extend by 
continuity of tissue into the Eustachian tube and middle ear. In case 
of an acute infectious exacerbation the middle ear and even the mastoid 
cells are likely to become involved. 

Collateral Symptoms. — Defective speech is a symptom of considerable 
22 



338 THE PHARYNX AND FAUCES 

diagnostic and economic significance. The voice is muffled and articu- 
lation is imperfect. The resonance, or timbre, of the voice is greatly 
impaired. 

Aural complications are present in a majority of cases. According 
to McBride and Turner, who analyzed 307 cases, 255 had involvement 
of the ear. Of the 255 cases, 144 were suppurative and 111 were more 
or less deaf with non-suppurative ear disease. They say: "We have 
more than once noticed in children (affected with adenoids) suffering 
from non-suppurating otitis media that in those in whom the mem- 
brana tympani had assumed an appearance which can but be likened 
to that of ground glass, especially when there was a permanent pinkish 
tinge, the prognosis as to improvement by subsequent treatment was 
not good, sometimes positively bad." 

It appears, therefore, that the aural complications, whether of the 
suppurative or non-suppurative type, may be serious. 

Diagnosis. — The diagnosis in most cases is so obvious that it scarcely 
warrants special mention. There are exceptional cases, however, in 
which an error may be made. It may be stated as an almost universal 
rule that when the tonsils are hypertrophied adenoids are also present. 
Conversely, it cannot be said that when adenoids are present the tonsils 
are also hypertrophied, as statistics show that only 30 per cent, of the 
cases with adenoids had apparent enlargement of the tonsils. It appears 
that the adenoids most easily undergo enlargement, the tonsils next, 
and the lingual less than either of the other lymphatic structures com- 
posing Waldeyer's ring. 

The fringe of the adenoids on the posterior wall of the pharynx, just 
below the line of the soft palate, is quite characteristic. When these 
nodules are present in a child, I am quite certain of the diagnosis, even 
without further examination, though I do not recommend that the 
examination should stop here. 

The epipharyngeal mirror should be used, when possible, to enable 
the surgeon to see the adenoids and their distribution. In many cases 
this method of examination cannot be adopted on account of the reflex 
closure of the palatal muscles against the posterior pharyngeal wall. 

When the mirror cannot be used the index finger of the right hand 
should be introduced through the mouth into the epipharynx for the 
purpose of detecting the gelatinous worm-like mass of adenoid tissue. 

It is not sufficient to merely determine the presence of a large adenoid 
cushion in the vault, or on the superior posterior wall of the epipharynx, 
but the examiner should determine whether the fossae of Rosenmiiller 
or the tubal orifices are covered by the growths. Adenoids are not 
removed merely because they are enlarged, but because of the epipharyn- 
gitis which almost always attends them and on account of their presence 
in the fossse of Rosenmiiller and the Eustachian orifices, even though 
they are small. 

Fibrous tumors of the epipharynx are sharply defined and are dense 
in texture, whereas adenoids are not sharply defined and are soft in 



ADENOIDS 339 

texture, hence there need be no difficulty in making a differential diag- 
nosis. 

Malignant tumors of the epipharynx can scarcely be mistaken 
for adenoids if an ordinarily careful examination is made. The hemor- 
rhage, cachexia, and other symptoms readily distinguish the cancer- 
ous growths. 

Tuberculous and syphilitic granulomata rarely simulate adenoid 
growths. Carel has reported two cases of tertiary syphilis, and Ler- 
moyez a case of tuberculosis of the epipharynx, which closely resem- 
ble'd, in general symptomatology, adenoid growths. 

Prognosis. — The prognosis from the standpoint of the mentality of the 
patient varies from slight retardation to an almost complete arrest of 
mental development. The improvement in the mental growth after oper- 
ation is often marvellous, provided the operation is performed during the 
natural period for such development, e. g., during infancy and childhood. 
If the removal of the growth is delayed until the individual has prac- 
tically attained full growth, the mind will rarely develop as it would 
had they been removed at an earlier period. 

The general health rarely improves during infancy and childhood so 
long as adenoids remain. If, however, they are removed, the blood 
becomes red from free oxygenation and all the vital energies are quick- 
ened and increased. 

The " facial or adenoid expression" improves somewhat with advancing 
years, though it often remains as a permanent disfigurement through 
life. If the adenoids are removed sufficiently early in life the " adenoid 
expression" often disappears, or its further development is prevented. 

The early removal of adenoids often prevents serious aural complica- 
tions, improves the general health, and beautifies the face. 

Treatment. — There is but one treatment worthy of the name, and that 
is the surgical removal of the growth. Astringent applications have been 
and are still advocated by some writers, but in my opinion their use is 
but a means to postpone the day when their removal must take place. I 
can conceive how a congestion and inflammation of the lymphoid masses 

Fig. 235 



La Force adenotome 



might be relieved and greatly improved by the local use of alkaline and 
astringent washes, but when true hypertrophy has occurred the curette 
or forceps offer the best means of treatments 



340 



THE PHARYNX AND FAUCES 



Adenoids may be removed with the Meyer ring curette through the 
nose, though this is an almost obsolete method. A more rational and 
effective method is with a Boeckmann curette or some modification of it. 
During the last few years I have depended more and more upon an 
instrument of the La Force pattern (Fig. 235). 



Fig. 236 



s 




Lateral position of the patient under general anesthesia for the removal of adenoids and tonsils. 

Technique. — The following technique may be employed for simple 
adenectomy, though in combined adenectomy and tonsillectomy anes- 
thesia by ether is preferable (Figs. 236 and 237). 

Fig. 237 




Furguson-Pynchon mouth gag. 

(a) Nitrous oxide anesthesia. 

(6) The removal of the adenoids with the La Force adenotome is 
performed as follows: The blade of the instrument is withdrawn, 
leaving the fenestra open. The instrument is then introduced into 
the fauces, the tip turned laterally, engaging behind the patient's 
right posterior pillar. It is then turned upward into the epipharynx. 
The adenoid is engaged by pushing the instrument upward and back- 
ward. The blade is then pushed home, cutting the adenoid from its 



ADENOIDS 



341 



attachment. The instrument is then removed, opened and the adenoids 
removed from it. 



Fig. 238 




Removal of adenoids with the Boeckmann-Stubbs curette. The arrows indicate the three 
movements necessary for the complete operation in a normal epipharynx. 

Fig. 239 




Removal of adenoids with the Brandegee forceps. The remnant (a) left in the anterior por- 
tion of the vault just posterior to the septum should be removed with the Stubbs modification 
of the Boeckmann curette. 

(c) Introduce the curette (Fig. 238) in the same manner and engage 
the mass at the anterior portion of the vault just behind the posterior 
end of. the septum, as the adenotome often fails to remove the adenoid 
tissue in this position (Fig. 239, a). 

(d) Introduce the right index finger into the epipharynx and rub 
away any shreds and remnants of adenoid tissue which may remain. Also 



342 



THE PHARYNX AND FAUCES 



explore Rosenmiiller's fossse with the finger tip and remove the fibrous 
adhesive bands should any be present. 

(e) The patient's head should then be held over the fountain cuspidor 
until bleeding stops or consciousness is restored. 



Fig. 240 




1, normal vault of the epipharynx from which adenoids may be removed with the Boeckmann 
curette; 2, posterior wall of the pharynx; 3, posterior end of vomer in its normal relation to the 
hard palate; 4, uvula; 5, hard palate; 6, sphenoid sinus. 



Fig. 241 




An epipharynx with an angular superior pouch from which adenoids could be removed with 
the Boeckmann curette, except possibly the upper angle of the pouch. This region might 
necessitate the use of a special curette. 1, 2, 3, 4, 5, and 6 refer to anatomical points (Fig. 240). 



During the operation the patient may be in the sitting posture, 
preferably in the lap of an assistant. He should be wrapped tightly with 
a sheet in order to prevent his arms getting in the way during operation. 

I sometimes operate without a general anesthetic if the patient is 



ADENOIDS 



343 



old enough to submit without resistance. 



The pain is not great and 
the danger from an anesthetic is obviated. It should be said, however, 
that the danger from nitrous oxide gas is practically nil, whereas the 
records show that several cases have died under chloroform. 



Fig. 242 




An epipharynx with a shallow posterior pouch from which the adenoids could be removed with 
the Boeckmann curette, except in the posterior portion of the pouch: 1, a slight recess in the 
posterior wall of the vault of the epipharynx in which adenoids are inaccessible to the Boeck- 
mann curette; 2, 3, 4, 5, and 6 refer to anatomical points. (After Moure). 

Fig. 243 




An epipharynx with a deep pouch in the posterior wall, from which adenoids could not be removed 
with the Boeckmann curette. Such cases should be operated on through the nose with Wilhelm 
Meyer's ring curette (Fig. 245), or with a special curved curette (Fig. 246). 



Stubbs' Method. — According to Stubbs, the blade of the curette should 
be drawn forward against the septum, lifted upward against the vault, 
and then pushed directly backward until the posterior wall is reached. 
The blade of the curette should then be drawn downward over the 



344 



THE PHARYNX AND FAUCES 



posterior wall and quickly brought forward into the cavity of the mouth 
(Fig. 238). If the curette is as wide as the epipharynx, one introduc- 
tion of the instrument usually removes the entire growth. Stubbs has 
modified the Boeckmann curette to adapt it to this technique. 

According to Moure, the epipharyngeal space varies greatly in shape, 
a fact which largely determines the completeness with which adenoids 
may be removed with the usual form of curette and forceps. If the 
epipharyngeal space is normal in shape (Fig. 240), the curette and 
forceps will completely remove the adenoids. If there is a recess in the 
vault (Fig. 241), these instruments will fail to remove all the tissue. If 
there is a recess in the posterior wall of the epipharynx (Figs. 242 and 
243), the forceps and curette of the usual type will fail to remove all the 
tissue. These facts may account for the non-success of many adenoid 



Fig. 244 




Special curette for reaching the recesses in the vault of the pharynx. 
Fig. 245 



Meyer's ring curette. 
Fig. 246 





Pynchon's modification of Golding Bird's curette. 



operations. If there is a recess in the upper wall of the epipharynx, a 
specially designed curette (Fig. 244) should be used to complete the 
operation. If there is a recess in the posterior wall of the epipharynx, 
the Meyer ring curette (Fig. 245) introduced through the nose, or 
Pynchon's modification of Golding-Bird's curette shown in Fig. 246, 
or Quilan's forceps, should be used to complete the operation. 

George L. Richards advises the removal of adenoids under general 
anesthesia with the Shutz adenotome. He believes that by this method 
a more complete removal is attained. The adenotome is inserted into 
the epipharynx and pressure is exerted upward and backward while 
the blade is being closed. This method has the advantage of pre- 
serving the specimen intact for inspection. H. Gradle's adenotome 
is also a good instrument, and is preferred by some operators. The 



ADENOIDS 345 

objection to all such instruments is that they do not adapt themselves 
to the peculiar conformation of the epipharynx shown in Figs. 240 
to 243. They also fail to remove the portion of the growth located 
in the lateral portions of the pharynx. If, however, the adenotome is 
followed by the use of a suitable curette, as Stubbs' modification of 
Boeckmann's model, the result is good. 

Whatever method of removal is used, the ultimate aim should be the 
complete removal of the adenoids, as otherwise they will probably 
recur. 

Sequelae. — The Face. — The development of the face is often materially 
modified by the presence of adenoids. The open mouth, the absence of 
the nasolabial folds, the short upper lip, the protruding and twisted 
central incisors of the upper jaw, the broad, flat, upper half of the nose, 
and the narrow, slit-like nasal openings, all conspire to form the so-called 
" adenoid face." The general expression is one of stupidity. The 
degree of facial disturbance varies greatly in different cases, usually 
in proportion to the degree of the nasal respiration, rather than the 
actual size of the adenoid growths. According to J. E. Schadle, the 
average capacity of the epipharynx is about 17 c.c, and its lateral is 
longer than its anteroposterior diameter. If the capacity of the epi- 
pharyngeal space is diminished, or its anteroposterior diameter is con- 
tracted, a small adenoid mass may produce a greater nasal obstruction 
than a larger growth in a more roomy epipharynx. The facial expression 
is more modified in the former than in the latter instance. It should 
not be deduced from the foregoing statements that the indications for 
treatment are in proportion to the degree of nasal obstruction per se, as 
there are several other conditions resulting from small as well as large 
adenoids that necessitate their removal. 

Interior of the Nose. — The interior of the nose is also modified in 
its development. J. S. Thompson called attention to this fact in an 
article wherein he states that the loss of the physiological stimulation 
incident to nasal respiration results in underdevelopment of the turbinate, 
and that deviated septa are common. Such individuals are subject to 
intranasal disease, for obvious reasons. 

Hard Palate. — Adenoid subjects usually have a palate which is 
"gothic" or arched, especially in its anterior portion. The arch is ap- 
parently higher than normal, though, as Newkirk has shown by numerous 
casts, the increased height is apparent rather than real. The illusion 
arises from the fact that the lateral diameter of the upper jaw contracts 
while the height of the arch remains the same; this produces a marked 
disproportion between its width and height. 

The Teeth. — The contraction of the lateral diameter of the arch some- 
times causes the central incisors to protrude and to be twisted upon their 
axes so as to cause their posterior surfaces to face each other. The teeth 
are often irregular, and the services of a dentist are required to regulate 
them. 

Epipharyngeal Inflammation. — When adenoids are present the epi- 
pharyngeal mucous membrane is almost always the seat of local inflamma- 



346 



THE PHARYNX AND FAUCES 



Fig. 247 




tions of both the acute and the chronic type. The low resistance of the 
adenoid tissue, the rarefied or abraded cylindrical epithelium, the reten- 
tion of the secretions, and the insufficient ventilation of the epipharyngeal 
space all promote inflammatory processes. The inflammation may 
be lacunar, either acute or chronic, or it may be a diffused catarrhal 
inflammation which affects the mucosa covering the adenoids and the 
adjacent structures. 

The Auditory Apparatus. — Adenoids are a prolific source of inflamma- 
tion in the Eustachian tube, middle ear, and mastoid process. It is a 

common clinical experience that 
children with adenoids who com- 
plain of recurrent attacks of earache 
are relieved by tympanic inflation. 
The Eustachian tubes are closed 
by catarrhal swelling, or " plugged" 
with thick, tenacious mucus, and 
the air in the tympanic cavity be- 
comes absorbed and rarefied. 

The drumhead is retracted and 
the mucous membrane which lines 
the tympanic cavity is hyperemic. 
Catarrh of the tubes and middle 
ears is thus established. 

Suppurative otitis media is also 
caused by adenoids. The infective 
material from the epipharynx enters 
the tubes and middle ears during 
A the acts of coughing, sneezing, or 

other violent movements of the phar- 
yngeal and palatine muscles. Then, 
too, the ciliated columnar epithelium 
of the tubes may become atrophic 
or broken down by the pressure of 
the opposed walls from the catarrhal 
swelling. The absence of the cilise 
permits easy ingress of the infected 
secretions into the middle ear, and 
infection thus becomes established 
in the tympanic cavity. 
Having gained a foothold in the tympanic cavity, it is but another 
step for the infection to invade the mastoid cells. The inflammation of 
the middle ear and mastoid process is usually proportionate to the viru- 
lency of the microorganisms which cause it. The labyrinth may also 
become involved in the infective inflammations of the middle ear, though 
such an occurrence is rare. Deafness, in some degree, is always present 
in the foregoing aural complications of adenoids. 

The Respiratory System. — The anterior nasal openings are narrow and 
slit-like, while the turbinated bodies are underdeveloped. The conditions 






I i 



Deformity of the chest due to adenoids. 



ADENOIDS 347 

are favorable for the development of catarrhal inflammation of the mucosa 
of the nose. The lateral walls of the chest are contracted (Fig. 247), 
thus throwing the ensiform cartilage into prominence. This character- 
istic deformity is known as " pigeon chest." The lungs are also under- 
sized and respiration is shallow. The transfusion of gases through 
the walls of the air vesicles is impaired. Too little oxygen passes into 
the blood, and too little carbon dioxide is thrown off. The patient is 
both anemic and nervous, and is often irritable to a marked degree. 

The Ecnes. — Frederick Coolidge called attention to the apparent 
relationship existing between adenoids and the various forms of club foot. 
I have often verified the saying that "if you will show me a bow- 
legged man I will show you one who had adenoids in infancy." Adenoids 
affect the nutrition, partly through anemia and partly through an excess 
of carbon dioxide in the blood. These two conditions cause faulty metab- 
olism and nutrition. The bones are deficient in lime salts, hence are 
soft and bend easily under the weight of the body. 

The Blood. — Adenoid patients are usually anemic. The red blood 
corpuscles are deficient in number and in hemoglobin. Carbon dioxide 
is present in excess. The nutrient elements are diminished in quantity 
and quality. 

Fig. 248 




Pharyngeal scissors. 

Thornwaldt's Disease. — This condition is characterized by a suppura- 
ting canal in the recessus medius or groove between the lateral halves 
of the adenoids. It is due to the inflammatory adhesion of the median 
borders of the adenoid masses. That is, the recessus medius, a groove 
between the lateral halves of the adenoids, becomes converted into 
a canal. The lining membrane of the canal becomes infected and 
discharges a purulent secretion. The symptoms are those of chronic 
pharyngitis attended with a cough. 

The canal may be seen by the use of a throat mirror, and a curved 
probe may be passed upward into it. 

The author's method of treating it is to introduce one blade of the 
curved pharyngeal scissors (Fig. 248) into the canal and then to cut off 
one lateral half of the adenoid mass (Fig. 249). This is a better way 
than to attempt to remove the adenoids in the usual manner, as the 
fibrous canal is so dense that it can be cut with difficulty. The posterior 



348 THE PHARYNX AND FAUCES 

and remaining portion of the canal wall should be thoroughly curetted 
to remove the pyogenic membrane. 



Fig. 249 

d 




Operative treatment of Thornwaldt's disease: a, the left blade of the pharyngeal scissors 
introduced into the suppurating sinus between the lateral halves of the adenoids; b, the right blade 
of the scissors at the border of the adenoid tissue. When the blades are closed the lateral half 
of the adenoids upon this side is severed. The scissors are then transferred to the other lateral 
half of the adenoid tissue and closed. This completely severs the lower portion of the adenoid 
tissue, and obliterates the suppurating sinus. The remaining upper portion of the adenoids, c, c, d, 
is then removed with the scissors or with a curette. 



THE LINGUAL TONSIL 

The lingual tonsil is situated- on the base of the tongue between the 
faucial tonsils, and extends anteroposteriorly from the circumvallate 
papillae to the epiglottis. It is divided in the median line by the median 
glosso-epiglottic ligament. The tonsil consists of numerous rounded 
or circular crater-like elevations, which are composed of lymphoid tissue, 
which at their circumference are surrounded by connective tissue. In 
the centre of each crater the mouth of the duct of a mucous gland opens. 
The crater or crypt is lined by stratified pavement epithelium. 

The lingual tonsil usually reaches its greatest development in young 
children, and, like the other tonsillar structures, may begin to atrophy 
at the age of puberty, though in adults these structures are often undi- 
minished in size. In the adult the number of the masses is generally 
greatly reduced, though they may be greatly hypertrophied. 

Here, as in the other portions of the tonsillar ring surrounding the 
oropharynx, leukocytes are thrown out in great abundance. 



THE LINGUAL TONSIL 349 

Acute Catarrhal Lingual Tonsillitis. — Acute catarrhal inflammation 
of the lingual tonsil is characterized by a moderate rise of temperature, 
painful deglutition, and a burning, pricking sensation in the throat. 
There may be some tenderness on pressure in the region of the great 
cornu of the hyoid bone. Upon inspection the pharynx and the pillars 
of the fauces may be slightly reddened, while the faucial tonsils may 
appear normal. The laryngeal mirror shows the masses on the lingual 
tonsil to be greatly reddened and swollen (Lennox Browne). 

Treatment. — The treatment consists in brushing the inflamed masses 
with a 20 to 50 per cent, solution of the nitrate of silver. 

Acute Lacunar Lingual Tonsillitis.— The symptoms of acute 
catarrhal inflammation are present, and in addition the craters or 
crypts are lined with a whitish exudate, epithelial debris, and micro- 
organisms quite similar to the accumulations found in acute faucial 
lacunar tonsillitis. 

Treatment. — The treatment consists of the local application of a 20 to 
50 per cent, solution of the nitrate of silver. 

Acute Phlegmonous Lingual Tonsillitis. — This process is usually 
characterized by a purulent accumulation beneath the lymph nodules at 
the base of the tongue, and is usually limited to one side. The tempera- 
ture is elevated and the pain upon deglutition is severe. The patient 
complains of soreness and great tenderness upon pressure in the region 
of the great cornu of the hyoid bone upon the affected side. Inspection 
with the throat mirror shows great swelling and redness at the base of 
the tongue upon the affected side. Palpation with the finger may or 
may not elicit fluctuation. 

Phlegmonous inflammation here, as in the faucial tonsil, may undergo 
resolution without the formation of an abscess. 

Treatment. — Treatment consists of incisions into the swollen tissue. 

Hypertrophy of the Lingual Tonsil. — Hypertrophy of the lingual 
tonsil is rare in children. It usually occurs between the twentieth and 
the fortieth years of life. It is more common in females than in males. 
It is probably caused by repeated or continued infection of the lymph 
structures of the pharynx, fauces, and epipharyngeal tonsils. 

Symptoms. — The symptoms are sometimes absent, though the sensa- 
tion of a foreign body in the throat is usually complained of. There is 
a pricking sensation, as though a splinter had lodged in the fauces, or 
the patient complains of the sensation of a lump, a hair, or other foreign 
body in the throat. Paresthesia of the pharynx presents the same symp- 
toms (Ball), and hence neurosis of the pharynx must be differentiated 
from this condition. So also must foreign bodies. According to Lennox 
Browne, troublesome fits of coughing are often present. 

During meals the symptoms disappear. Pain is rarely complained of, 
but the disagreeable sensation already referred to is present. The use 
of the voice increases the symptoms, and often gives rise to the pricking 
sensation and the cough. 

Upon examination with the throat mirror a few enlarged masses are 
seen upon the base of the tongue. The involvement is usually on both 



350 



THE PHARYNX AND FAUCES 



sides, but may be limited to one. The masses may be so large as to push 
the epiglottis backward or even to overhang it. 

According to Ball, Seifert emphasizes the value of the use of the probe 
and of cocaine in the diagnosis between paresthesia of the pharynx and 
hypertrophy of the lingual tonsil. With a probe the surgeon is enabled 
to locate the sensitive areas giving rise to the symptoms, and the applica- 
tion of cocaine causes these areas upon probing to give forth no symptoms. 

Treatment. — The treatment is essentialy surgical. Local applications 
of glycerin iodine, gr. xx to xxx to the ounce, afford relief by reducing 
the swelling and sensitiveness. Linear cauterization of the masses is 
an effective treatment, though the removal of the masses with stout 
curved scissors has proved to be the best treatment in my experience 
(Fig. 250). 



Fig. 250 




Removal of the lingual tonsil with heavy scissors. 



Lingual Varixj Varicose Veins.— Lennox Browne, in his treatise 
on the Throat and Nose, says that varix occurs in 10.6 per cent, of the 
cases at the Central London Throat, Nose, and Ear Hospital. As early 
as 1863, G. Lewin, of Berlin, reported that the symptoms of pharyn- 
gitis varicosa were sensations of scraping, burning, and dryness of the 
pharynx. Since then many writers have reported similar cases, so that 
its existence as a rather common form of disease is well established. 
I have seen cases in my own practice which presented the clinical picture 
described by Browne and others. It occurs more frequently in males, 
according to Browne (69 per cent.), though Swain and Seiss found it 
more frequently in females, while Seifert found it equally prevalent among 
both. Excessive and improper use of the voice is an exciting cause. It is 
rare in childhood and most common between the twenty-fifth and forty- 



THE LINGUAL TONSIL 351 

fifth years. Infectious inflammations of the pharynx and faucial tonsil 
and infection of the lymphoid tissue of the lingual tonsil probably 
are the chief etiological factors. On account of the greater resistance 
to these influences possessed by the lingual tonsil, hypertrophy in this 
region does not occur as early in life as it does in the faucial and pharyn- 
geal tonsils. Hence, chronic infectious processes are often necessary 
to establish the hypertrophy of the lingual tonsil and varix of the veins. 
Browne believes that a constitutional or acquired debility of the vaso- 
motor system is the chief cause. Some cases are reported as occur- 
ring at the period of the menopause. Constipation and an obstructed 
portal circulation are etiological factors of some importance. 

Pathology. — I am indebted to Escat for the information that, accord- 
ing to Verneuil, "superficial varices only make their appearance when the 
deep varices have acquired a certain development." Escat also says: 
"Many kinds of neuralgia, otherwise inexplicable, are today attributed 
to circulatory troubles in the satellite veins of the nerves, and to a con- 
secutive neuritis/' Quenu has thus explained certain neuralgias: "The 
trunk of the lingual nerve, the evident seat of a glossodynia, is in effect, 
according to Foucher, accompanied by a satellite vein, and even by two 
according to Zuckerkandl." This anatomical fact is held by Escat to 
support his hypothesis, and that of Piotrawski, that all neuroses in this 
situation may be attributed to varices, superficial and deep. 

Symptoms. — As lingual varix is usually associated with hypertrophy 
of the lingual tonsil, the symptoms are about the same. Upon inspection, 
tortuous veins, bluish in color, are seen at the base of the tongue partially 
hidden by the hypertrophied tonsil. 

Treatment. — The treatment consists in the application of the galvano- 
cautery to the enlarged veins, and the removal of the hypertrophied 
lymphoid masses with the cautery point or with scissors. I have fre- 
quently resorted to these methods of treatment with satisfactory results. 
The after-treatment consists in gently massaging the wounds with a 
cotton-wound applicator dipped in a mixture of equal parts of glycerin, 
tr. ferri chloridi, and tr. iodini, at intervals of twenty-four hours. This 
prevents exuberant granulations, and promotes healing with a smooth 
wound and a minimum of cicatricial contraction. 



CHAPTEE XVIII 

INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES 
SIMPLE ACUTE CATARRHAL PHARYNGITIS 

This form of acute pharyngitis is usually accompanied by acute 
rhinitis, or "cold," though the pharynx may be chiefly affected. 

Etiology and Pathology. — The etiology and pathology is the same 
as that of acute rhinitis. Digestive disorders are an important factor 
in causing the disease. 

Symptoms. — The onset is characterized by malaise and a slight rise 
in temperature, as in acute rhinitis. The borders of the soft palate and 
uvula are slightly red, while the adjacent mucous membrane is normal 
in appearance. As the disease progresses the uvula becomes slightly 
edematous and the secretions are increased; it may become markedly 
edematous and painful, though this is not common. The tonsils are 
not usually involved, though they may be in severe cases. Pain is usually 
present, especially upon swallowing, and stiffness and aching of the 
muscles of the neck are complained of. Dysphagia or painful swallowing 
is a constant symptom. 

Diagnosis. — The erythema of secondary syphilis may be confounded 
with this disease. The differential points are: (a) The darker or dusky 
color (in syphilis) of the mucous membrane; (b) the more marked involve- 
ment of the tonsils and soft palate, the diminished secretion; (c) the 
line of demarcation between the inflamed area and the hard palate; 
(d) the dusky symmetrical patches on the anterior pillars ; (e) the opales- 
cent appearance of the mucous membrane of the tonsils and the per- 
sistence of the disease, as contrasted with the evanescence of acute 
catarrhal pharyngitis. 

Treatment. — As the acute affection is somewhat dependent upon the 
presence of chronic rhinitis and sinuitis, these conditions should receive 
appropriate attention. The methods of treatment given for acute rhinitis 
are also of value, as the morbid process is almost identical. 

The anatomical peculiarities and the associated digestive disorders, 
however, render special modes of treatment necessary. 

Local treatment should vary according to the stage of the inflammation. 
Broadly speaking, astringents should be used in the first and third stages 
and sedatives in the second stage (Parker). They may be applied as 
gargles, sprays, paints, or lozenges. Gargles are suited to inflammations 
of the soft palate, uvula, and anterior pillars of the fauces. Sprays and 
paints are especially good methods of making local applications. Pre- 
liminary to all local treatment the alimentary tract should be evacuated. 
(352) 



CHRONIC PHARYNGITIS 353 

From 5 to 10 grains of calomel, and six hours afterward a tablespoonful 
of castor oil, should be given. The following morning a tablespoonful 
of Epsom salt should be given to flush the bowels (Stucky). After this, 
the patient's condition is favorable for a speedy recovery under simple 
local treatment. 

The following mixture is recommended by Parker: 

1$. — Borax gr. xxiv 

Glycerin TT| xxiv 

Tincture of myrrh TT| xxiv 

Aquse des q. s. ad 5j 

Sig. — Use every hour as a gargle. 

If preferred, a gargle composed of 6 grains of alum, 15 grains of chlorate 
of potassium, to the ounce of water, may be used. 

The patient may be supplied with lozenges containing krameria or 
catechu, with instructions to dissolve one of them in his mouth every 
three hours. A cold compress should be worn across the front of the 
neck. 

After twelve hours, red gum lozenges, which are very sedative, may 
be substituted for those containing krameria and catechu. A simple 
gargle containing 15 grains of the chlorate of potash to the ounce of 
water may also be used every three hours. 

The inhalation of steam charged from a croup kettle with the com- 
pound tincture of benzoin, one tablespoonful to the pint of boiling water, 
should be used if the throat is painful. 

Pastils containing 3 grains of bismuth and \ grain of the acetate of 
morphine may also be dissolved in the mouth every three hours to relieve 
a painful throat. 

Should edema of the uvula occur, it should be scarified or amputated. 



CHRONIC PHARYNGITIS; GRANULAR PHARYNGITIS; LACUNAR 
PHARYNGITIS, OR CLERGYMAN'S SORE THROAT 

This disease may or may not be characterized by severe subjective 
symptoms, such as irritability and dryness of the throat. 

Etiology. — The chief factors in the etiology of this disease are gouty 
and rheumatic diatheses, smoking, improper breathing (public speakers 
and singers), and the presence of morbid processes in the nose, accessory 
sinuses, and the epipharynx. Gouty or rheumatic patients complain 
of throat symptoms, whereas if they are free from gout and rheumatism 
they often make no such complaint. These conditions probably not 
only aggravate the pharyngitis, but to a certain extent influence its 
occurrence. Excessive smoking also aggravates and produces the inflam- 
mation. Clergymen, singers, auctioneers, and hucksters, who breathe 
through their mouths and abuse the vocal apparatus, are frequently 
affected by chronic pharyngitis. Chronic rhinitis, and especially sinuitis, 
affecting the posterior ethmoidal and sphenoidal cells is very frequently 
the chief cause of the disease. The changed respiratory functions of the 
2<3 



354 THE PHARYNX AND FAUCES 

nose in these diseases subject the pharynx and the lower respiratory 
tract in general to irritation. Of even greater importance is the discharge 
of heavy mucous or mucopurulent secretions from the nose and accessory 
sinuses into the pharynx. The secretions are charged with pathogenic 
bacteria, and undergo decomposition, whereby certain irritating chemical 
products are liberated, and as the secretions flow over the pharynx the 
pathogenic bacteria attack the weakened mucous membrane and excite 
inflammatory reactions. The chemical irritation also adds to the reaction. 

I wish, therefore, to emphasize the importance of making a careful 
examination of the nose and accessory sinuses in all cases of chronic 
pharyngitis. 

Pathology. — The changes in the mucous membrane consist at first 
of an increased, hyperemia and local leukocytosis, and later of the deposit 
of the least differentiated cells or connective-tissue cells. That is, hyper- 
plasia of the mucous membrane occurs. The lymph tissues around 
the tubular glands of the pharynx are enlarged and are raised above 
the surface of the mucous membrane. Occasionally the tubular glands 
in the centre of the lymphoid masses are filled with a whitish exudate 
or cheesy material. 

Symptoms. — Subjective symptoms are not always present, especially 
if the patient is not gouty or rheumatic, or if he does not misuse his voice. 
In gouty and rheumatic patients who smoke to excess or breathe im- 
properly the subjective symptoms are usually present. 

Subjective Symptoms. — In aggravated cases the voice becomes hoarse 
after moderate use, especially in public speakers, though the cords are 
neither red nor inflamed. According to Lennox Browne, the hoarseness 
is due to a spasm of the muscles of the pharynx and irritation of the 
superior laryngeal nerve. 

Smokers complain of a dryness or of the sense of a foreign body in 
the throat. They have a constant desire to hawk and expectorate. 

Cough may be present, though it is often absent. When present it 
is irritable and hacking in character. 

The secretions in the early stage of the disease are excessive, thick, 
and tenacious. At a later stage the glandular functions become impaired 
and the throat dry and glazed. 

The digestive tract is disordered, the breath foul, and constipation is 
generally present. 

Objective Symptoms. — Upon examination of the pharynx the mucous 
membrane appears redder than normal, at least in certain areas. In 
other areas it is pale and fibrous in appearance, especially in old chronic 
cases. Enlarged bloodvessels often extend across the posterior pha- 
ryngeal wall. The secretion is often thick, heavy, and mucopurulent, 
though in the later stages it may be scanty and only forms a film over 
the surface. In these cases the patient complains of dryness of the 
throat. The uvula is often relaxed and elongated (Fig. 252), and should 
be amputated. 

The lymph follicles of the posterior wall and of the lateral walls behind 
the posterior pillars of the fauces are enlarged. This condition is often 



EDEMA OF THE UVULA 



355 



Fig. 251 



referred to as pharyngitis hyperplastica lateralis, a needless subdivision 
of chronic pharyngitis. The follicles are sparsely distributed on the 
posterior wall of the pharynx, but are closely grouped along the lateral 
walls. They appear as yellowish-red, raised areas on the posterior wall 
and as nodular, elongated masses behind the posterior faucial pillars. 

Prognosis. — In the early congestive stage, simple astringent and 
demulcent local remedies combined with the regular use of a mild aperient 
mineral water will effect a cure. In the more advanced cases in which 
hyperplasia of the mucous mem- 
brane has occurred, and in which 
the lymph follicles are hyper- 
trophied, improvement will only 
follow the destruction of the 
tubular glands around which the 
lymph masses are located. 

Treatment. — In mild cases 
and during the early stage of 
the disease, or before marked 
hyperplastic and hypertrophic 
changes have taken place, the 
remedies given under acute 
catarrhal pharyngitis may be 
used with some success. 

Aperient salines should be 
given daily for a long period to 
eliminate the gouty and rheu- 
matic toxic material and to free 
the stomach and intestines of 
putrefactive substances. 

In well-advanced cases the 
lymphatic nodules, whether dis- 
crete or massed, as they may be on the lateral walls behind the posterior 
pillars of the fauces (pharyngitis hyperplastica lateralis), should be punc- 
tured with a cherry-red cautery electrode (Fig. 251). The mucous, 
membrane should be brushed once or twice with a 10 per cent, solution 
of cocaine, and from four to five hyperplastic follicles burned out with 
the electrode. A spray of Seller's solution, to soothe the burned areas, 
should then be used. At the end of the fifth or sixth day, four or five 
more follicles may be treated in a similar manner, and so on until they 
are all destroyed. This course of treatment is often very beneficial, 
though it may fail if the gouty or rheumatic diathesis is not also cor- 
rected. The uvula should be amputated if it is elongated. 




Showing the cautery point applied to pharyngeal 
follicular glands in the treatment of follicular 
pharyngitis. From four to five follicles may be 
thus treated at a sitting under cocaine anesthesia. 



EDEMA OF THE UVULA 

Acute inflammation of the faucial structures, especially of the periton- 
sillar tissue, is frequently attended by edema of the uvula (Fig. 252). 
The methods of treatment generally recommended are scarification or 



356 THE PHARYNX AND FAUCES 

multiple punctures, which allow the excess of serum to escape. A more 
rational procedure would be to promote a freer flow of the blood through 
the tissues, and thus remove the obstruction to the blood current 
through the veins. The application of the rays of light and heat from 
a 500 candle-power electric lamp to the neck at the angle of the lower 

Fig. 252 




Edema of the uvula. 

jaw acts admirably in this way. The lamp should be suspended at a 
distance of eighteen inches from the patient and slowly passed back and 
forth over the neck for from fifteen to thirty minutes, three times daily. 
The patient's neck should then be sponged with ice- water in order 
to prolong the hyperemia. 

Astringent lozenges containing krameria and alum will be found 
efficacious in giving comfort to the patient. 

ELONGATED UVULA 

Elongation of the uvula is not a disease per se, but is a symptom of a 
chronic pharyngitis, especially epipharvngitis. The relaxed pendulous 
condition of the uvula is due to the irritation resulting from the epi- 
pharyngeal discharge and to the changed nutrition attending the epi- 
pharyngeal infection and inflammation. The uvula may be slender and 
pendulous, or it may be enlarged (hypertrophied) and pendulous. An 
elongated and elastic uvula is sometimes observed as an idiopathic 
condition, as shown in the author's case (Figs. 253 and 254). 

Symptoms. — In robust subjects it causes but slight symptoms or none 
at all. In sensitive patients it often causes a reflex cough when it touches 
the epiglottis or the base of the tongue. The cough may be spasmodic, 
and is usually dry. Nausea and vomiting, especially early in the morning, 
are sometimes complained of. Patients have applied to me for relief 
from the persistent hacking cough, fearing that they had tuberculosis. An 
examination of the lungs failed to reveal disease in that region, whereas 
an examination of the throat showed the presence of a long pendulous 



ELONGATED UVULA 



357 



uvula. The amputation of the lower relaxed portion of the uvula imme- 
diately stopped all symptoms. 

Treatment. — In simple cases, astringent remedies, such as lozenges 
containing krameria, afford relief. The uvula may also be painted with 
astringent solutions of alum, tannic acid, or with adrenalin. In the 



Fig. 253 



Fig. 254 



A 


-.~\ 

* 








.-^ * — 


*/ 


i 


A^ 

89 m 


__~. 


\^ 


^r 


y 




\ 




Author's case of elastic uvula. Note the spiral 
arrangement of the mucous membrane of the uvula 
when the muscle of the uvula is contracted. (See 
Fig. 254.) 

Fig. 255 



Author's case of elastic uvula, evinc- 
ing no tendency to elongation when at 
rest. (See Fig. 253.) 




The amputation of the elongated tip of the uvula just below the lower extremity of the muscle. 
The scissors are so applied that the posterior surface of the uvula will be the wounded surface. 
This prevents irritation in swallowing food and in breathing through the mouth. 



more severe cases amputation is indicated. In all cases the epipharynx 
and the mesopharynx (oropharynx) should be examined and the diseased 
conditions treated. 



358 



THE PHARYNX AND FAUCES 



Surgical Treatment. — (a) The uvula should be painted with a 10 per 
cent, solution of cocaine. 

(b) The tip of the uvula is then seized with forceps and drawn directly 
forward. 



Fig. 256 



a v ^ 

ITT 



Three views of the amputated uvula: a, anterior view; b, lateral view; c, posterior view. 



Fig. 257 






Casselberry's operation for elongated uvula. 



(c) While in this position it should 
be operated upon with heavy blunt 
scissors, as shown in Fig. 255. 

By cutting the uvula from in front 
while drawn anteriorly, the bevelled 
cut surface of the stump faces pos- 
teriorly. This is a point of practical 
importance, as in swallowing solid 
food the raw surface is not irritated 
by it (Fig. 256). 

Casselberry's Operation. — Dr. Wm. 
E. Casselberry recommends the fol- 
lowing technique in the amputation 
of the uvula: 

(a) Secure anesthesia by painting 
the uvula with a 10 per cent, solu- 
tion of cocaine. 

(b) Seize the tip of the uvula with 
forceps and draw it directly forward. 

(c) While in this position an up- 
ward and medianward cut is made 
with scissors to the central axis of 
the uvula. A similar cut is made on 
the opposite side, thus removing a 
wedge-shaped piece of the uvula, 
as shown in Fig. 257. 

(d) The anterior and posterior cut 
edges of the wound are then secured 
with two or three black silk sutures, 
black thread being used, because it 



RETROPHARYNGEAL ABSCESS 359 

is easier to see at the time of its removal. Yankauer's needles may 
be used with advantage. 

(e) The sutures should be removed at the end of three days. 

The advantages claimed for this method of operating are that the 
cut surfaces are sealed and not likely to be irritated by the ingested 
food, nor infected by ingested and inhaled pathogenic bacteria. 

Hemorrhage has been reported after uvulotomy. This may be avoided 
by limiting the amputation to the portion of the uvula below its muscu- 
lar fibers; that is, only the thin relaxed portion should be removed, as the 
bloodvessels of the uvula do not extend beyond the muscular fibers. 



RETROPHARYNGEAL ABSCESS 

Abscess of the posterior wall of the pharynx may be acute or chronic. 
It may be situated in the mesopharynx, the hypopharynx, or the epi- 
pharynx. 

Etiology. — There is an infection beneath the mucous membrane. 
The morbid germs gain entrance through the lymph vessels, the atrium 
of invasion being in one of the neighboring tissues which is diseased. 
Tonsillitis, a postoperative tonsillar wound, a tuberculous tonsil, tuber- 
culous cervical glands, caries of the vertebra, and syphilis of the throat 
may be the immediate predisposing causes. The author observed one 
case which followed the complete excision of the tonsil in an adult. Most 
of the chronic cases occur in tuberculous and strumous children. Post- 
pharyngeal abscess is often associated with tuberculous glands of the 
neck. The glandular involvement is probably secondary to the pharyn- 
geal abscess, or both may be secondary to a tuberculous affection of 
some other structure. 

Symptoms. — The patient complains of painful deglutition, and, if the 
swelling is in the hypopharynx, of dyspnea, which may threaten life 
or even cause death. Cough is constantly present. The voice is much 
the same as in quinsy. In acute cases the temperature may be elevated 
from 1° to 2°, whereas in chronic ones it is little altered. 

Diagnosis. — The abscess should be differentiated from aneurysm, 
malformation of the vertebrae, and inflammatory swelling of the mucous 
membrane. 

Aneurysm of an artery in this region has been mistakenly diagnosticated 
as retropharyngeal abscess, a fatal issue following the incision. The 
pulsation and bruit present in aneurysm should be sought for in all cases 
of suspected abscesses of the pharynx. The pulsation may be noted 
with the eye or finger, while the bruit may be distinguished with the 
stethoscope introduced through the mouth. 

Malformation of the posterior wall of the pharynx, causing bulging 
of one side, is occasionally found. The hard, firm character of the mass 
readily distinguishes it from the soft baggy mass which is present in 
abscess formation. 

Acute infectious inflammations of the pharyngeal mucous membrane 



360 



THE PHARYNX AND FAUCES 



sometimes simulates retropharyngeal abscess. The difference in the 
resistance upon digital examination will determine which of the pro- 
cesses is present. 

Prognosis.— The danger in very young subjects is chiefly due to 
suffocation, and to strangulation upon the spontaneous rupture of the 
abscess. In older patients this danger is not so great, as their reflexes 
enable them to ward it off or to anticipate it. Under treatment the 
prognosis is nearly always good except when the disease is due to 
tuberculous caries of the vertebrae. 



Fig. 258 




a 



The oral operation for retropharyngeal abscess. The finger is used as a guide to the fluctuating 
area and as a tongue depressor, while a short-bladed scalpel is used to open the abscess. 



Treatment. — The most important object to be accomplished is the 
immediate evacuation of the pus. This may be done by (a) the internal 
or (b) the external route. The internal operation should always be 
tried first, and followed by the injection of iodoform glycerin emulsion 
(Esmarch and Kowalzig). Should simple puncture and evacuation, 
followed by the injection of the iodoform emulsion, fail, the external 
operation should be performed. 

Technique. — Internal Operation. — (a) Place the patient upon a table 
with his head lowered to prevent the larynx being bathed in pus. With 
children this precaution is especially urgent, because their reflexes are 
not sufficiently trained to prevent suction of the infected secretion into 
the trachea and lungs, where it might cause aspiration pneumonia. 



RETROPHARYNGEAL ABSCESS 361 

(b) Introduce the left index finger into the mouth and place the tip 
against the soft fluctuating tumor. 

(e) Introduce a short-bladed scalpel, or a longer one, the proximal end 
of which is wrapped with a strip of adhesive plaster or cotton, into the 
mouth, using the above-mentioned finger as a guide (Fig. 258). 

(d) Incise the abscess wall by the side of the finger. The pus then 
flows through the incision into the pharyngeal cavity, from which it may 
be removed with moist gauze sponges, grasped by artery forceps; or it 
may be expectorated by the patient. 

(e) After all the pus has been thus removed, irrigate the cavity with 
warm boric acid solution and inject the iodoform glycerin emulsion into 
the wound. The injections may be repeated every day or two, and if 
steady improvement follows, a cure may be expected. If, however, im- 
provement does not follow, the external operation should be performed. 

Fig. 259 





The external operation for retropharyngeal abscess. The fascia enclosing the abscess is punctured 
and opened with artery forceps. 

External Operation. — Generally speaking, the external operation 
consists in making an incision either anterior or posterior to the sterno- 
mastoid muscle, and extending it inward by blunt dissection to the 
anterior wall of the vertebral column, where the abscess cavity is located. 

If only the retropharyngeal abscess is to be included in the operation 
the incision should be made posterior to the sternomastoid muscle; if, 
however, there are diseased cervical glands to be removed at the same 
time, the incision should be made anterior to the muscle (Fig. 259). 

The following steps in the operation should be observed: 

(a) The field of operation should be shaved and cleansed. 

(b) General anesthesia. 

(c) An incision two or three inches long should be made through the 
skin over either the anterior or the posterior border of the sternomastoid 
muscle on a plane with the retropharyngeal abscess. The dissection 



362 THE PHARYNX AND FAUCES 

should be continued until the deep cervical fascia is opened and the 
border of the sternomastoid muscle is brought to view. 

(d) The sternomastoid muscle is then separated by blunt dissection 
from the adjacent tissues, and is drawn forward with a retractor to 
expose the operative field. 

(e) Still using blunt dissection, the carotid sheath, with its vessels and 
nerves, is separated from the vertebra and carefully drawn forward. 

(/) The dissection is carried in front of the vertebra to the abscess 
wall. 

(g) The abscess wall is punctured with closed artery forceps; the 
forceps is then introduced into the cavity, the blades spread apart, and 
withdrawn from the cavity (Fig. 259). The abscess is thus freely opened 
and evacuated. 

(h) Digital examination of the cavity should be made for necrosed 
bone, and to note the condition of the soft tissues and abscess contents. 
If the secretions are thick and caseous, they may be removed by gentle 
curettage. 

(i) Irrigation with warm boric acid or the glycerin-iodoform solution 
completes the evacuation of the contents of the abscess. 

(f) Introduce a cigarette drain into the wound. This may be with- 
drawn a little each day after the discharge has ceased, and its use may 
be abandoned altogether at the end of ten days or two weeks, after 
which the external wound closes from the bottom by granulation. 

If cervical glands are to be removed, or if the abscess points anteriorly 
to the sternomastoid muscle, the incision should be made anterior to the 
muscle. The group of glands involved should be removed en masse, as 
to leave some of them almost surely means a secondary operation. 



MALFORMATIONS OF THE PHARYNX; STENOSIS OF THE PHARYNX 

Malformations of the pharynx may be either (1) congenital or (2) 
acquired. 

Those of congenital origin may be in the form of an imperforate 
pharynx, from a failure in the embryological development of the anterior 
end of the foregut, and the invagination of the ectoderm, which forms 
the cavity of the mouth. The embryological structures in this region are 
very complex, and it is remarkable that congenital malformations are 
not more frequent. They usually occur in the form of a constriction 
or pouch, or of a complete closure. 

Acquired malformations are due to inflammatory and degenerative 
changes in the walls of the pharynx. Syphilis is the most common 
cause. In the tertiary stage there is more or less destruction of the uvula 
and soft palate, which is followed by cicatricial contraction and adhesion 
to adjacent parts. The soft palate in these cases is usually adherent to 
the posterior wall of the pharynx, and may cause most complete sepa- 
ration of the mesopharynx from the epipharynx. In one of my cases 
due to congenital syphilis there was a small opening, about the size of a 



MALFORMATIONS OF THE PHARYNX 363 

lead pencil, which communicated with the epipharynx. The scars in 
syphilis are stellate in their arrangement, i. e. , they radiate from the site 
of the original ulceration. The ingestion of scalding fluid and caustic 
drugs may produce scar tissue and cicatricial contraction. (See Syphilis 
of the Pharynx.) 

Treatment. — The treatment of syphilitic scar tissue and adhesions 
result in failure in the majority of cases. The scar tissue may be re- 
moved and the adhesions broken down, though they speedily reform 
and readhere. Obturators have been used in the isthmus between the 
mesopharynx and epipharynx, to keep the channel open and to prevent 
adhesions, with occasional success. The tendency for syphilitic scar 
tissue to reform, in spite of all that can be done, is the chief hindrance 
to the successful treatment of these cases. If the constriction involves 
the hypopharynx and dyspnea develops, tracheotomy should be per= 
formed. 



CHAPTEK XIX 

FUNCTIONAL NEUROSES OF THE PHARYNX 

Neuroses of Sensation. — The train of symptoms in pharyngeal 
neuroses of sensation is about the same as in the larynx, many of them 
being due to reciprocal lesions. (See Neuroses of the Larynx.) 

Anesthesia of the pharynx is not of any great clinical significance, 
excepting, perhaps, when it accompanies progressive bulbar disease. 

Insane patients generally have it, even though no form of paralysis is 
present in the pharynx or elsewhere in the body. In cases of marked 
anesthesia involving the whole pharynx, the soft palate and larynx are 
usually likewise anesthetic. Diphtheria often causes it, and sometimes 
it accompanies the other exanthematous fevers. It may be present in 
local inflammations of the pharyngeal mucosa. (For treatment, see 
Anesthesia of the Larynx.) 

Hyperesthesia of the pharynx is the most frequent of the pharyngeal 
neuroses. It often occurs in those who are otherwise healthy. These 
cases do not tolerate the laryngoscopic mirror in throat examinations. 
They also resist the introduction of the Eustachian catheter. The most 
sensitive areas in the pharynx are the arch of the soft palate and the 
vault of the epipharynx. 

Hyper sensitiveness accompanies both acute and chronic inflammation 
of the pharynx. It is also a frequent manifestation of hysteria. It is 
more common in men than women. Habitual smokers and drinkers 
are subject to it, It is but rarely a symptom of central brain disease. 
The hypersensitive areas sometimes appear on the tongue. 

Paresthesia occurs about as frequently as anesthesia, and less fre- 
quently than hyperesthesia, and often baffles the skill of examiners and 
operators. Tonsillar disease is often the cause of it, hence these organs 
should be thoroughly examined for diseased conditions. The passage 
of a bolus of food or foreign body may cause an abrasion, which may be 
followed by the sense of a foreign body in the throat. The menopause 
is frequently attended by perverted sensations in the pharynx. Patients 
at this period sometimes complain of the sensation of a rope or hairs 
in the throat. Hyperplasia of the lingual tonsil seems in some cases to 
cause it. The same is true of elongation of the uvula, though the elon- 
gated uvula is usually a sign of epipharyngitis, and the paresthesia 
may be due to the "dropping" from the epipharyngeal region. Granular 
pharyngitis, especially when it involves the lateral walls (pharyngitis 
hypertrophica lateralis), gives rise to an irritation between the posterior 
pillars and the pharyngeal wall, which is sometimes accompanied by 
paresthesia. It is occasionally associated with globus hystericus. 

The perverted sensations complained of are cold, heat, a foreign body, 
itching, tickling, and the dislocation of the essential parts of the fauces 
(364) 



FUNCTIONAL NEUROSES OF THE PHARYNX 365 

and pharynx. Patients sometimes complain of swallowing the soft 
palate, etc. Most of the female cases seen by me have suffered from 
melancholia during the menopause, and have had a suicidal tendency. 
One patient committed suicide by drowning some months after she 
passed from under my observation. The paresthesia may be so marked 
as to cause a distressing cough and laryngeal or esophageal spasm. 

Neuralgia of the pharynx is difficult to differentiate from muscular 
rheumatism. Neuralgia is not painful upon pressure, while rheumatism 
is painful with or without pressure. Anemia and chlorosis are often 
the cause of neuralgia, whereas rheumatism is more often associated 
with plethora. Enlarged single pharyngeal follicles may become so 
painful as to simulate neuralgia. Localized pressure upon the follicles 
causes pain in rheumatic pharyngitis. 

The treatment of neuralgia should be addressed to the cause when it 
can be determined, as well as to the relief of the pain. Iron, strychnine, 
arsenic, bitter tonics, and the regulation of the bowels should be the 
basis of the treatment in those cases in which anemia is the cause. In 
chlorosis, enemata should be given to unload and cleanse the rectum 
and lower bowel, to stop the absorption of putrefactive material and 
bacteria into the circulatory system. Exercise in the open air, especially 
upon cloudy days, is of the greatest value in these cases. Excessive 
exposure to sunshine is injurious, as it is too stimulating. Oxygen 
rather than sunshine is the desideratum. Patients should be encour- 
aged to play golf or other outdoor sport, or to work in the flower or 
vegetable garden, or in the poultry yard. The outdoor exercise should 
have a constant and alluring motive, or it will soon be abandoned. 

Neuroses of Motion. — Neuroses of motion of the pharyngeal muscles 
may, like that of the larynx, be divided into two general classes: 

1. AJcinesis, or paralysis, which may be unilateral or bilateral. The 
akinesis, or paralysis, may be still further subdivided into: (a) Paralysis 
due to bulbar disease (central paralysis), (b) Paralysis due to diph- 
theria (peripheral paralysis), (c) Paralysis due to or complicating faucial 
paralysis (central or peripheral paralysis), (d) Paralysis of the pharyn- 
geal constrictors (Lennox Browne). 

2. Hyper kinesis, or spasm. 

Paralysis Due to Bulbar Disease; Central Paralysis. — The following 
central lesions may give rise to pharyngeal paralysis; acute and chronic 
bulbar myelitis, hemorrhage, tumors, embolism, and basilar meningitis. 
Acute Bulbar Paralysis; Central Paralysis. — Symptoms. — In acute bulbai 
myelitis the symptoms develop rapidly, a fatal issue soon following. 
The symptoms are as follows: 
(a) Sudden attack. 
(6) Severe headache. 

(c) Dysphagia. 

(d) Respiratory embarrassment 

(e) Difficulty in articulation. 

(f) Giddiness. 

(g) Unsteady gait. 



366 THE PHARYNX AND FAUCES 

Prognosis. — The prognosis is extremely grave. 

Treatment. — While these cases are almost necessarily hopeless, they 
should be treated, as there is a chance that the diagnosis may be erroneous. 
Bloodletting by cupping or leeching should be early and freely done to 
relieve the inflammatory process at the base of the brain. Ice should be 
applied to the pharynx and to the nape of the neck. The blood tension 
should be lowered by the administration of cathartics and such other 
remedies as are employed for spinal myelitis. 

Chronic Bulbar Paralysis; Central Paralysis. — Undue exposure to cold, 
prolonged violent excitement, extreme fatigue, and lack of nutrition are 
etiological factors. Heredity seems also to largely influence its occur- 
rence. It is more common in males than in females, and is rarely ob- 
served before the age of thirty-five. In rare cases it may be due to an 
injury or to sunstroke. Syphilis and tuberculosis should also be included 
as causative agents. 

Symptoms. — Pharyngeal paralysis may be the first symptom of pro- 
gressive bulbar disease, though the tongue is usually the first organ 
affected. The tongue is first involved in a typical case, and this is followed 
by paralysis of the lips and of the pharyngeal and laryngeal muscles. 
This order of involvement is almost always present. The paralysis, at 
first slight, gradually increases in severity. 

Diagnosis. — In the beginning the disease may be mistaken for bilateral 
facial paralysis, though the history of a sudden onset, followed by pro- 
gressive chronic paralysis of the tongue, pharynx, and larynx, together 
with the lips, should render the diagnosis of bulbar paralysis almost 
certain. In bilateral facial paralysis the tongue, pharynx, and larynx 
are not affected. In rare cases the tongue and fauces are not involved. 

Prognosis. — The prognosis is usually grave, though there may be 
remissions before death occurs. Patients often succumb to inanition or 
pneumonia. 

Treatment. — Galvanism has been used to combat the degeneration 
of the nerves, and faradism to maintain the muscular vigor, with but 
little success. Strychnine and arsenic are of greater value. In syphilitic 
cases the iodides are indicated. 

Diphtheritic Paralysis; Peripheral Paralysis. — Paralysis of the pharyngeal 
muscles is often an early sequel of diphtheria and of pseudomembranous 
sore throat. The muscle fibers undergo more or less degeneration from 
the presence of the bacterial toxins, and there is a mechanical hindrance 
from the cellular infiltration of the tissues. In addition, there is a degener- 
ation of the peripheral nerve fibers from the same causes. 

Symptoms. — The voice undergoes great changes on account of the 
paralysis of the pharyngeal muscles, as they are utilized in articulation 
and voice placement. The voice has the so-called "nasal quality," 
closely resembling that present in cleavage of the hard and soft palates. 
The velum and uvula are relaxed and can only be raised by forced 
inspiration. One side or both may be affected. The paralysis occurs 
on or about the fifteenth day after convalescence, at which time ocular 
symptoms may also develop. 



FUNCTIONAL NEUROSES OF THE PHARYNGES 367 

Treatment. — The prophylactic treatment consists in the administration 
of antitoxin during the diphtheria. After the paralysis has developed, 
galvanism, faradism, and rectal feeding should be adhered to in order 
to maintain muscular and nervous tone while the degenerated nerve 
fibers are being restored. Thick soups, grape juice, etc., may be given 
per rectum. 

Paralysis of the Pharynx Complicating Facial Paralysis. — According to 
Ziemssen and Bouche, when the lesion is above the geniculate ganglion, 
the pharyngeal is often associated with facial paralysis. The uvula does 
not move upon phonation and is deflected to one side. The symptoms 
are the same as those in diphtheritic paralysis, and include such structures 
as are supplied by the seventh nerve. 

Paralysis of the constrictor muscles of the pharynx is always accom- 
panied by paralysis of the esophagus. The dysphagia is, therefore, 
exceedingly well marked, and is often the only distinctive symptom. 

Hyperkinesis, or Spasm of the Pharynx. — Etiology.— Spasm of the 
muscles of the pharynx is a rare affection. It may occur from insig- 
nificant causes, as uvulitis, foreign bodies, globus hystericus, enlarged 
pharyngeal follicles, neuralgia, and local chronic inflammations, or 
it may be an early symptom of a serious central lesion. 

The more dangerous form of spasm of the pharynx is encountered 
in hydrophobia, edema of the glottis, brain tumors, paralysis agitans, 
and other affections of the nerves. 

Symptoms.— Chronic spasm of the pharynx involving the soft palate 
and uvula may be the chief symptom. The levator palati is the muscle 
affected. The spasm of this muscle draws the soft palate upward a 
number of times in rapid succession, after which it relaxes. During 
the spasm there is a clicking noise as the palate leaves the pharyngeal 
wall. The click is audible to those near by. 

Prognosis. — The prognosis is fair in those cases due to simple causes, 
provided appropriate treatment is instituted. If due to a serious central 
lesion, hydrophobia, edema of the glottis, brain tumor, or paralysis 
agitans, it is grave. 

Treatment. — If the spasms are due to a foreign body, it should be 
removed. If due to local inflammation, appropriate remedies, else- 
where described, should be used. When due to saprophytic absorption 
from the rectum, the lower bowel should be flushed by enemata, outdoor 
exercise advised, and a nutritious but unstimulating diet followed. When 
due to hydrophobia, this should be treated rather than the spasms of the 
pharynx which are incidental to the disease. Stimulants of any sort 
should be avoided in all cases. 



CHAPTEE XX 

NEOPLASMS OF THE PHARYNX 
BENIGN NEOPLASMS 

(a) Papiilomata. — Papillomata rarely occur on the walls of the 
pharynx, but are common in the faucial region. They are most fre- 
quently found upon the uvula, the free borders of the pillars of the fauces, 
and the tonsils. The histological differences between the mucous mem- 
brane of the posterior wall of the pharynx and the mucosa of the uvula, 
pillars, and tonsils account for the location of the tumors. The posterior 
wall of the pharynx is covered by squamous epithelium, whereas the 
other structures are covered by columnar, and in many places by col- 
umnar ciliated epithelium. In spite of the varying structural differ- 
ences, papillomata appear in all parts of the pharynx and fauces, though 
more frequently in the fauces. 

They may be single or multiple, sessile or pedunculated. Behind 
the fauces, or in the pharynx proper, they are rarely pedunculated, and 
are chiefly limited to the ragged excrescences following syphilitic and 
lupous inflammations. Papillomata are composed of elevations of epi- 
thelial cells which contain a connective-tissue core more or less richly 
supplied with bloodvessels. The epithelial elevations grow outward, 
while in epitheliomata they grow inward. The elevations vary from 
tumors as small as a pinhead to those of considerable size. They often 
contain "pearls" or "nests," which may be mistaken for the nests or 
pearls of epitheliomata. The cells in papillomata are uniform, whereas 
in epitheliomata they are multiform. Epitheliomata are likely to be 
mistakenly diagnosticated as papillomata, and vice versa. 

Primary papillomata are usually surrounded by an inflammatory area. 
Secondary papillomata are the result of a preexisting inflammation, 
as syphilis (Fig. 260). 

The presence of a papillomatous growth in the fauces or pharynx 
often excites a reflex cough, with a sense of fulness and tickling in the 
throat. 

Treatment. — The treatment of papilloma of the pharynx is usually 
so simple that a detailed description of the procedures need not be given. 
The tumor should be removed to its base with a knife, snare, cutting 
forceps, or cautery. The base of the growth should be removed or 
cauterized with a solid stick of nitrate of silver or the galvanocautery. 
If this is not done they are likely to recur. 

(b) Teratomata. — Lennox Browne says: The connection between 
teratomata and cystomata is so intimate and their origin so obscure 

(368) 




BENIGN NEOPLASMS 369 

that it is expedient to describe them together. I shall not do this, but 
will attempt to characterize them as distinct pathological entities. 

Teratoma ta are usually congenital and consist of tissue growths 
springing from two or three embryological germinal layers. They appear, 
therefore, most frequently in those regions where the various germinal 
layers are in close apposition (Browne). The pharynx, which develops 
from the junction of the neural and the dermal epiblasts with the hypo- 
blasts of the foregut is, therefore, a suitable location for the growth of 
teratomata. Bland-Sutton called attention to this fact in 1886. 

Teratomata generally occur in the epipharynx, though in quite a 
few recorded cases they were in the meso- and hypopharynx. They 
were sometimes called " hairy pharyngeal polypi," as they are usually 
pedunculated cysts filled with hair and other histological structures. 

Conitzen reported 11 "hairy 
polypi," or teratomata, which were FlG - 260 

cystic and contained hair, carti- 
lage, skin, and bone. The cysts 
are usually pedunculated, and may 
be attached to any part of the 
pharynx. 

Treatment. — The treatment con- 
sists in the removal of the growth 
with the snare, knife, or cautery. 
Cauterization of the base seems to 
prevent recurrences. , ,',„.', 

s \ /1 ±, j. rpi ii Author s case of follicular tonsillitis and syphi- 

(C) OyStOmata. 1 hese USUally ]itic papilloma arising from the left supratonsillar 

occur after the twentieth year of fossa. 
life, more often in middle and 

advanced age. They are usually retention cysts or mucoceles, due 
to the closure of the mouths, of the pharyngeal follicles, either by 
inflammatory contraction, epithelial plugs, or by the flaccid folds of 
membrane in advanced life. The cysts contain a glairy fluid, though 
in some cases it is inspissated and much thickened. They are usually 
superficially located, though Raugi speaks of the occurrence of a cyst 
in the submucous tissue. This tumor was difficult to see, and he thinks 
this type must occur much more often than is generally believed. 

Cysts are usually sessile, and often give rise to the symptoms described 
under reflex neuroses, as asthma, migraine, etc. 

Treatment. — The treatment consists in the enucleation of the cyst 
membrane, though thorough cauterization of the lining of the sac is 
usually followed by the obliteration of the tumor. 

(d) Lymphomata, or Lymphadenomata. — This variety of benign 
tumor is the most frequent growth in the pharynx. This is to be expected 
on account of the widely disseminated lymphoid tissue and the numerous 
lymphoidal vestiges. The matrix of the tumor is connective tissue. 
in the meshes of which are aggregated the lymphoid cells. The cell 
groups are often crowded together and vary greatly in size. They, 
like lymphoidal tumors elsewhere, have a strong tendency to multiply. 
24 



370 THE PHARYNX AND FAUCES 

They may be attended with or may follow mediastinal complications of 
a like nature (Villar). A single tumor, especially when pedunculated, 
at times offers some diagnostic difficulties. But when we take into 
consideration that the adjacent lymphatic glands in the neck are 
enlarged and soft, the tumor in the pharynx, though pedunculated, 
should be suspected to be lymphomatous. 

0) Myxomata— Myxoma of the pharynx is exceedingly rare. 
Browne in his large experience never saw a case. Closely allied to 
them, however, are the so-called mucoceles due to dilatations of the 
mucous glands. The mucoceles are important as they are readily 
recognized and are easily eradicated by excision or the actual cautery. 

(/) Fibromata.— The structural arrangement is often so like that of 
sarcomata that it is difficult to differentiate them. The clinical history 
is, therefore, the guide in diagnosis. In very rare instances a myxo- 
matous tumor may have the tendencies and aspects of a fibroma, just 
as primary fibromata may become mucoid in character. Fibromata 
are rare in advanced age, but are quite common in young and middle 
adult life. This seems to be true of nearly all neoplasms springing 
from the mesoblast. 

Fibromata may be sessile, but are more often pedunculated. They 
are composed of densely packed spindle cells, with an undeveloped 
matrix of connective tissue. They are encapsulated, and often attain 
a large size. Bruns reports a case in which the entire fauces was filled 
by a fibroma. They are usually single and of slow growth. They 
have their origin in the fibrous tissue and the periosteum of any part 
of the pharynx. The covering of the basilar process of the occipital 
bone and body of the sphenoid -are favorite sites. As the pterygoid 
plate of the sphenoid and the perpendicular plate of the palate bone, 
the posterior ends of the upper turbinated bodies, and the posterior 
portion of the vomer are all covered with fibrous tissue and perios- 
teum, fibromata usually develop in this region. Large fibromata are 
frequently attended with inflammatory processes, hence adhesion to the 
adjacent structures is common. 

Etiology. — They are rare in females. Age is a decided factor in their 
occurrence, adolescence being the favorite period. As age advances there 
is a tendency for the growths to recede or undergo spontaneous cure. In 
this respect they resemble adenoids and other lymphatic enlargements. 

Symptoms. — The early symptoms are those of epipharyngeal catarrh, 
with more or less hemorrhage. The bleeding sometimes becomes an 
alarming complication. The voice becomes "flat" or "dead" in quality, 
and respiration and deglutition are impeded as the process advances. 
At a later stage, there is pain and mucopurulent discharge. When the 
growth has attained considerable size, the "frog face" becomes well 
marked, the maxillary bones are separated, and exophthalmos becomes 
a prominent symptom. Aprosexia and drowsiness are often present. 
In one of the author's cases the patient often dropped into sleep or slight 
stupor while in the treatment chair. Greville Macdonald reports vomit- 
ing as an annoying symptom. 



BENIGN NEOPLASMS 



371 



If the growth extends upward it may encroach upon the cranial con- 
tents and give rise to such symptoms as paralysis, etc.; this is followed 
in nearly every instance by death. 

The foregoing symptoms increase in severity as the growth extends, 
until the absorption of bony tissue is considerable, unless the tumor 
extends beyond the nasal and pharyngeal chambers, as into the cranial 
cavity. In this event the pressure necrosis of the bony tissue is not 
so great. 

Examination shows the tumor to be a rounded mass, of a pinkish or 
dark purple color. The veins are frequently varicosed, hence the 
examination by digital or instrumental aids should be done carefully, to 
avoid injuring them. The growth may project into the posterior nares, 
or its direction may be toward the antrum and other sinuses. Under 
finger pressure it is firm and elastic, and if small its base may be out- 



Fig. 261 




Author's case of soft fibroma of the epipharynx, springing from the base of the sphenoid and 
sending finger-like prolongations into the nasal chambers. 



lined. If pedunculated, it is movable, unless it has become fixed by 
inflammatory adhesions. If it extends through the sphenomaxillary 
fissure, it may be felt under the zygoma. As adhesions are usually 
present, its outline is difficult to distinguish. 

In Fig. 261 is shown a soft fibroma of large size in a lad aged fourteen 
years. It had its origin from the base of the sphenoid bone and extended 
into the nasal chambers by three finger-like processes. Numerous 
inflammatory adhesions were present around the choana?. A general 
surgeon of repute made five futile attempts to remove the growth because 
he was not intimately familiar with the anatomy of the pharynx. (See 
Treatment.) 

Diagnosis. — The histological resemblance to sarcoma is often so close 
that a differentiation is difficult, unless the age, sex, and origin are such 
as to point to its fibrous nature. Sarcoma is rarely or never, whereas 



372 THE PHARYNX AND FAUCES 

soft fibroma is frequently, pedunculated. Hard fibromata are usually 
sessile. 

Prognosis.— The prognosis is favorable in proportion to its early recog- 
nition and extirpation. It is also favorable when the age of the patient 
exceeds twenty-five years. In other words, small fibromata which do 
not fill the epipharyngeal space are more favorable under operative treat- 
ment than those which completely fill it. The tendency of the growth 
to undergo retrograde changes after the twenty-fifth year accounts 
for the more favorable prognosis in those cases in which it occurs after 
this period. 

Some patients even recover spontaneously. It is advisable in nearly 
all cases to remove the growth by surgical interference, as it is too great 
a risk to wait for a spontaneous cure. An additional reason for oper- 
ating is to relieve the patient as speedily as possible of the pain and 
other distressing symptoms characteristic of these growths. 

Treatment. — Small growths, especially if they are pedunculated, and 
those limited to the epipharyngeal space may be removed with a heavy 
snare or ecraseur, either through the nose or mouth, or with adenoid 
forceps. The galvanocautery snare may also be used through these 
route's. When the growth is large and sessile, and has extensive inflam- 
matory adhesions to the adjacent structures, it may be necessary to 
perform an external or more radical operation. Large soft pedunculated 
fibromata like the author's case shown in Fig. 261 may be removed as 
follows: 

(a) Prepare the patient as for a major operation. General anesthesia. 

(b) Place the patient in Rose's position. 

(c) Be prepared to ligate the external carotid artery, and to introduce 
postnasal tampons. In the author's case, the hemorrhage was very 
great, and necessitated the ligation of the external carotid artery. Res- 
piration ceased at the same time, and artificial respiration was prac- 
tised while the carotid artery was being ligated. The hemorrhage 
occurred when the inflammatory adhesions around the choanee were 
being broken down with the finger. The patient was emaciated and 
anemic, which doubtless rendered the bleeding more severe. 

(d) Break down the inflammatory adhesions around the choanre with 
the finger, which should be introduced through the mouth. 

(e) Introduce curved pharyngeal scissors (Fig. 248) through the 
mouth into the epipharynx posterior to the body of the tumor until the 
pedicle of the tumor is reached, and sever it if possible. If the tumor 
is very large, this may not be possible. In the case shown in Fig. 261, 
I succeeded in partially severing the pedicle. 

(/) If the pedicle cannot be severed with the scissors, introduce 
strong, slightly curved adenoid forceps through the mouth into the 
vault of the epipharynx, seize the pedicle, and cut it from its attachment 
to the base of the sphenoid bone. By this method I removed the fibroma 
shown in Fig. 261. The growth was removed through the mouth; the 
finger-like extensions into the nasal chambers came away with the body 
of the tumor, as the adhesions within the nose were not firm. 



BENIGN NEOPLASMS 373 

The patient made a slow, but uneventful recovery, and two years after 
the operation is in excellent health. 

(#) Lipomata. — Lipomata of the pharynx are rare. When they occur 
they are usually small and sessile, especially when they develop from dense 
tissue. When they spring from loose tissue they may attain large size, 
and are generally pedunculated and multiple. They are oval, smooth, 
and elastic, hence are sometimes mistaken for retropharyngeal abscess. 
A puncture readily clears the diagnosis. They usually occur in advanced 
age. Lennox Browne says that the sessile and deeply seated ones are 
more often congenital than otherwise. 

(h) Angiomata. — Because of Cruveilhier's submucous plexus, situated 
at the back of the pharynx, and the rather rich, both superficial and 
deep, blood supply, we might naturally expect many angiomata. But, 
on the contrary, they are of rare occurrence. Moritz Schmidt does not 
cite a case in his excellent review of the tumors of the upper respiratory 
tract. Guyon had one patient in whom digital examination caused 
profuse hemorrhage. Electrolysis checked the hemorrhage, and sub- 
sequently caused atrophy of the growth. Angiomata of the pharynx, 
like similar growths elsewhere, are usually cavernous and often erectile 
in character. Farlow reports five cases of enlarged pulsating arteries 
in the pharynx. The red currant-like clusters occasionally seen in the 
pharynx are, strictly speaking, angiomatous. 

Treatment. — Most physicians favor non-interference unless the tumors 
bleed. This attitude is attended by some risk, because a serious hemor- 
rhage may occur at any time. If large, they should be deprived of their 
arterial blood supply by ligatures around the efferent vessels. If small, 
they may be treated by electrolysis or by ligation. 

Electrolysis is performed as follows: (a) Anesthetize the tumor with 
local applications of a 10 per cent, solution of cocaine. 

(b) Introduce the needles, connected with the positive pole of the 
galvanic battery, into the growth. 

(c) Turn on from 10 to 25 ma. of current for five minutes. Repeat the 
seances at intervals of about seven days until the growth is obliterated. 

The positive pole of the battery liberates nascent oxygen and coagu- 
lates the tissue, hence it is the pole which should be applied to a soft 
growth. If it is desired to reduce a hard or fibrous tumor, the negative 
pole is applied to the growth, because it liberates hydrogen, which softens 
the tissue. 

Ligation or strangulation may be performed as follows: (a) Anes- 
thetize the growth by the local application of a 10 per cent solution of 
cocaine. 

(b) Pass a ligature through the tissues, including an artery at the 
margin of the angioma, and tie it. Yankauer's needles should be used. 

(.c) Continue thus to tie off the larger vessels until the nutrient sources 
are closed. 

(d) After three or four days the ligatures should be removed. 



374 THE PHARYNX AND FAUCES 



MALIGNANT NEOPLASMS OF THE PHARYNX 

General Pathology. — Clinically, it is an advantage to make a distinct 
demarcation between the fauces and the pharynx in treating malignant 
growths. However, as is well known, their tendency to spread by con- 
tinuity of tissue and by metastasis, and their insidious beginning, does 
not permit of an absolute anatomical division. Oftentimes they origi- 
nate on the borderline between the two regions. It should be borne 
in mind that when these tumors spring from the larynx they are likely 
to extend to the pharynx, but that those arising from the pharynx seldom, 
if ever, extend downward to the larynx. Even those which occur in 
the hypopharynx have an upward rather than a downward tendency. 
This is partially explained by the difference in the tissues composing the 
two parts. In the larynx there is little soft tissue, and the glandular 
element is less, whereas in the pharynx the soft tissues and lymph glands 
are more abundant. 

Embryologically, the pharynx and the larynx have different origins, 
and the tendency to extension is thereby somewhat impeded. 

The general symptoms are much the same as those of cancer of the 
larynx. The special symptoms are dependent upon the anatomical and 
physiological differences in the two regions. 

The lower portion of the pharynx is more often the seat of malignancy 
than the upper. Men are more often affected than women. Carcino- 
mata here, as elsewhere, are more frequent in the old. This is in obe- 
dience to the physiological law, that mesoblastic structures are more 
active in the young, while the epi- and hypoblastic structures are more 
active in the old. An effort is made by some writers to differentiate 
between the malignancy of sarcoma and carcinoma. This is of no 
practical or clinical value, as either is usually the cause of death in whom- 
soever it occurs. True carcinoma, because of its glandular structure, 
more readily involves contiguous structures, and more frequently extends 
by metastasis. 

Carcinoma of the pharynx is more frequent than sarcoma. The 
former is more likely to involve the glandular structures, subjected as 
it is to persistent irritation, especially in the pharynx. Sarcoma may, 
however, be due to traumatism. 

It is often difficult to differentiate profuse scar tissue from sarcoma, 
as both are closely allied to embryonal tissue. The clinical phenomena 
are, therefore, often more reliable than the microscopic findings. 

Varieties of Sarcoma. — The various types of sarcoma which appear 
in the pharynx in their order of frequency are: 

1. Round-cell sarcoma. 

2. Spindle-cell sarcoma. 

3. Myxosarcoma. 

4. Lymphosarcoma. 

1. Round-cell Sarcoma. — The round-cell sarcomata are of two types: 
(a) Large round-cell sarcoma, and (b) small round-cell sarcoma. Their 



MALIGNANT NEOPLASMS OP THE PHARYNX 375 

structure is characterized by an aggregation of cells, intercellular cement, 
and numerous bloodvessels. Occasionally a few fibrous trabecular are 
distributed through the mass of cells. Lymph channels are also found 
in the cellular masses. The cells vary considerably according to their 
age and original site of growth. The older part of the tumor is in a 
state of degeneration, while the newer part is intact. The small round- 
cell sarcoma is softer than the large round-cell growth, which has 
more intercellular cement substance. The cells of the large round-cell 
sarcoma often have oval nuclei, and form the most malignant type 
of sarcoma. Its local ravages are extensive and the constitutional 
manifestations are severe. 

2. Spindle-cell Sarcoma. — This, like the round-cell variety, is divided 
into two classes: (a) Small spindle-cell sarcoma, and (b) large spindle- 
cell sarcoma. The general structure of this variety is quite like the round- 
cell sarcoma except that the cells are often arranged in bundles. Lymph 
spaces are absent, whereas they are present in the round-cell variety. 
The vascular supply is accordingly greater than in the round-cell variety. 
Many spindle-cell sarcomata have a tendency to undergo degeneration 
in patches, and are less malignant than the round-cell variety. The 
spindle-cell sarcoma more often occurs in adults, while the round- eel I 
variety is more often present in the young. The spindle-cell sarcoma 
develops slower than the round, is firmer, and less likely to ulcerate. 
It may be pedunculated, while the round-cell variety is seldom or 
never pedunculated. It is encapsulated and "shells out," while the 
round-cell is not encapsulated. 

The local malignancy is greater than in the round-cell variety, while 
the general malignancy is not so great. The spindle-cell sarcoma usually 
springs from the posterior wall of the pharynx, though it may arise 
from the lateral wall. 

3. Myxosarcoma. — Myxosarcoma is originally either spindle-cell or 
round-cell, which, having undergone an early mucoid change, is con- 
verted into the myxomatous type. It is locally malignant, rather than 
constitutionally; that is, it has a tendency to recur, but seldom gives 
rise to metastasis. It arises most frequently in the loose cellular tissue 
of the lateral wall of the pharynx, though it may occur in the fauces and 
the glosso-epiglottic fold. 

4. Lymphosarcoma. — Lymphosarcoma is a variety of round-cell sar- 
coma. It possesses a very delicate reticulum, which gives it the appear- 
ance of a lymphoid structure. It usually originates in the lymphoid 
tissue of the pharynx, which is, perhaps, another reason for its resem- 
blance to normal lymphoid or adenoid tissue. When the growth is 
traversed by numerous fibrous connective-tissue bands, it is more dense in 
structure. It is necessary to differentiate this neoplasm from benign hyper- 
plasia and lymphoma, which is directly due to inflammatory processes. 

Lymphosarcoma grows rapidly, and when removed invariably recurs. 
It usually involves everything in its course, especially that type which 
starts in the lymphatic glands. Pharyngeal lymphosarcoma is quite 
often observed in Hodgkin's disease, which is a true lymphosarcoma. 



376 THE PHARYNX AND FAUCES 



TRYPSIN TREATMENT OF MALIGNANT NEOPLASMS 

According to J. T. Campbell, the trypsin treatment of malignant 
neoplasms is based upon the statistical findings of von Bergmann, 
wherein he states (1) that cancer of the stomach stops abruptly at the 
pylorus; (2) that the small intestine is but rarely the site of cancer; and 
(3) that cancer of the large intestine and rectum for the most part 
increases in frequency the farther the distance from the duodenum. 
In 10,537 cases of cancer of the alimentary tract the stomach was involved 
4288 times, the small intestine 20, the large intestine 224, and the rectum 
1204 times. The natural and comparative immunity of the duodenum 
and small intestine, together with the slower rate of growth of cancer 
of the large intestine, would, therefore, appear to support the treatment 
of inoperable cancer by preparations of the pancreas, bile salts, intes- 
tinal gland extracts, and ferments alone or combined. In November, 
1905, Dr. Wade, at the solicitation of Dr. F. Beard, began experi- 
ments, first, to determine the action of trypsin upon the living cells of 
carcinoma, such as Jensen's mouse tumor (an adenosarcoma) ; second, 
to test the truth of the conclusion advanced by Beard in 1902 that 
cancer was an irresponsible trophoblast; and third, the length of treat- 
ment and number of injections of trypsin necessary to destroy the 
tumor. 

The results were such as to appear to show that the trypsin caused a 
deo'eneration of the cancer cells, a shrinkage of the tumor, and an im- 
proved condition of the system in general. Since then several cases of 
cancer in the human body have been reported wherein trypsin caused 
apparent shrinkage of the growth, a cessation of the pain, marked gain in 
weight, and great improvement in the health of the patients. It appears, 
however, that the improvement was temporary, in some of the cases a 
recrudescence of the neoplasm occurring later, with a rapid fatal ter- 
mination. It is too early to accurately judge the merits of the trypsin 
treatment. It is, however, worth trial in inoperable cases. An oper- 
able case should be operated early and thoroughly. Delay and partial 
removal by operation are dangerous procedures. An early operation 
and complete removal offer the best chance of a cure. The operation 
may be followed by the trypsin treatment. 

Technique of Trypsin Treatment. — The trypsin comes in sealed am- 
poules, of 20 minims each, of a glycerin extract prepared from the pan- 
creatic glands, and with such a proportion of the ingredients of the 
normal salt solution that when diluted with two volumes of sterilized 
distilled water the medium corresponds in this respect to the normal 
salt solution; greater dilution may be employed if desired. 

At first 5 minims of the trypsin solution diluted with 10 minims of 
sterilized distilled water should be injected through the skin of the 
buttocks deep into the subcutaneous tissue, but not into the muscles. 
The injections may be given every other day, gradually increasing the 
dose to 10 minims. 



EXCISION OF THE EXTERNAL CAROTID ARTERY 377 

The skin should be cleansed with soap and alcohol, and in sensitive 
patients 0.1 grain of eucaine may be injected a few minutes before the 
injection of the trypsin. 

Some writers recommend the administration of holadin in 3 grain 
capsules three times a day during the trypsin injections. Holadin is 
an extract of the entire pancreas gland, containing all the constituents 
of the digestive and internal secretions of the gland. 



EXCISION OF THE EXTERNAL CAROTID ARTERY AND ITS 

BRANCHES FOR INOPERABLE CANCER OF THE UPPER 

RESPIRATORY TRACT 

The excision of both external carotid arteries and their eight branches 
may be performed for the purpose of depriving inoperable malignant 
growths of the nose and pharynx of their blood supply, thereby starving 
the growths. Malignant tumors require a large blood supply, hence 
this operation seems to offer some degree of hope. Dawbarn reports 
encouraging results in a number of cases of inoperable cancer of the 
head. The operation should never be performed when the growth can 
be successfully extirpated. The ligation of the external carotids and 
their branches should be adopted as a last resort. While it may not 
cure the case, it may prolong life. 

Position of the Head. — The shoulders should be placed upon a block 
or sand cushion, the chin well elevated and everted to the opposite side 
to expose the region of operation. 

Incision. — The incision should extend from the tip of the mastoid 
process close behind the angle of the jaw to the level of the middle of 
the larynx. At either extremity the incision is exactly over the external 
carotid artery. Dawbarn recommends that the incision be curved 
medianward about 1.5 cm., as the safety of the operation lies anterior 
to the artery, while danger lies posterior to it. 

Exposure of the Artery. — Work from below upward, first exposing the 
superior thyroid artery, which extends downward to the thyroid gland. 
By tracing this back to the carotid the external is distinguished from the 
internal. Pass a chromicized catgut loosely around the external carotid. 
Examine the carotid and be sure that it bifurcates into the external and 
internal branches. If it does not it should not be ligated, as the blood 
supply to the brain would be cut off and death result. 

If it does not bifurcate into the external and internal branches, only 
the branches supplying the external portions of the head should be ligated, 
the carotid being untied.. Having determined that the common carotid 
bifurcates as usual, continue the dissection upward, exposing each branch 
and tying it in two places and dividing it. The dissection is thus con- 
tinued upward until the level of the twelfth cranial nerve is reached, and 
all the branches of the artery but the terminal two have been controlled. 
The external carotid is itself tied twice and divided between. The 
ligature placed loosely around the external carotid below the superior 



378 THE PHARYNX AND FAUCES 

thyroid branch should not be tied until all the branches are ligated. 
It should not be tied sooner, because the artery would collapse and 
render the dissection difficult. The ligature is placed in position early, 
ready for use in case of accidental hemorrhage in the course of the dis- 
section higher up. The upper portion of the artery should be dissected 
as it passes under the transverse loop of the twelfth nerve and the con- 
joined stylohyoid and posterior belly of the digastric and on into the 
substance of the parotid gland. It should be followed to its bifurca- 
tion when possible. The dissection should be done with dissecting 
forceps or scissors and not with a sharp knife, as it might divide some 
of the lower branches of the pes anserinus and cause facial paralysis, 
or else, by cutting through some of the smaller ducts of the parotid 
gland, cause a salivary fistula (Dawbarn). Use gentle downward trac- 
tion during the blunt dissection, and when as high as possible, seize 
the artery with artery forceps and tie as high above it as possible, and 
then sever the artery below the forceps. 

Close the wound by sutures, leaving a cigarette drain at its lower 
angle, or make a counteropening an inch and a half below the angle 
and insert the drain through this, entirely closing the original wound. 

At the end of five or six days the drain may be discontinued and the 
counteropening allowed to heal by granulation. 

Structures to be avoided: The internal jugular, internal carotid, pneu- 
mogastric, the superior laryngeal nerve, the pharyngeal branch of the 
pneumogastric, and the glossopharyngeal nerves. They all lie behind 
and deeper than the external carotid artery. Careful dissection should 
be done. 

The opposite carotid should be operated in like manner after an 
interval of ten days, though both maybe done at one time if the patient 
is in vigorous health. The death rate of this operation is considerable. 



CHAPTEE XXI 

DISEASES OF THE FAUCES AND TONSILS 
THE TONSILS AS PORTALS OF INFECTION 

Since Strassmann reported 13 cases of tuberculous tonsils in 21 tuber- 
culous cadavers, the tonsils have commanded considerable attention as 
channels of infection. The opinions of various observers since then 
have differed somewhat, especially in reference to the tuberculous pro- 
cess in the tonsils. There has been but little questioning of the fact, 
however, that the tonsils are portals of systemic and glandular infection. 
There is not, after all, a great divergence of opinion as to whether the 
tonsils are frequently a path of pathogenic infection; the difference 
is a question as to certain details, rather than as to the general theory 
itself. For example, some observers have failed to find tubercle bacilli, 
or the characteristic tuberculous changes in the tissue of the tonsils, 
which have been reported by other writers. Notwithstanding this, 
practically all writers agree that various pathogenic organisms do gain 
an entrance to the deeper tissue of the tonsils, the lymphatic glands, 
the lungs, the heart, and, indeed, to the whole system through these 
organs. 

In view of the growing interest and more exact information on this 
subject, the tonsils have gained a prominence in medical literature 
which they did not have a quarter of a century ago. A brief resume of 
current thought on this subject will, therefore, be given in connection 
with a study of the diseases of these organs. 

In reference to "primary tuberculosis of the tonsils, there is a divergence 
of opinion; some hold that the tuberculous process in these glands is 
direct, while others contend that the infection reaches them from the 
lungs through the lymphatics and the bloodvessels, or by the flow of 
the bronchial secretions over them. Both views are probably correct 
in selected cases. It is probable, however, that tuberculous infection 
of the cervical lymphatic glands is usually due to the entrance of the 
bacilli and other microorganisms through the tonsils. This is borne 
out clinically by the fact that suppurating or tuberculous glands of the 
neck are rarely found in phthisical patients. Whereas, if they occurred 
secondarily to pulmonary infection, they would be frequently found in 
such patients. 

That a latent tuberculous process may exist in the tonsils or in adenoids 
without presenting distinctive clinical signs thereof, is suggested by the 
reports of a few cases in which a fatal pulmonary tuberculosis followed 
the removal of tonsils and adenoids. Friedreich suo-o-ests that the removal 

(379) 



380 THE PHARYNX AND FAUCES 

of the tonsils may have excited a recrudescence of a latent tuberculous 
tonsillitis in these cases. It seems to me that these cases point strongly 
to the conclusion that there is such a condition as latent tuberculosis 
of the tonsillar ring, which may continually infect the lymphatic glands of 
the neck, as well as the deeper structures in the thoracic cavity. Latent 
tuberculosis of the tonsils is not per se a serious menace to the health 
or life of the patient, but the danger arises from the extension of the 
infection to the contiguous organs. 

The experiments of Dieulafoy show that of 96 guinea-pigs inoculated 
with pieces of tonsils and adenoids, 15 developed tuberculosis. While 
these experiments are not conclusive in their scope or character, they 
are, nevertheless, suggestive. We know that tubercle bacilli are found on 
healthy mucous membranes, and it is possible, though not probable, that 
in these experiments the infection may have come from the accidental 
presence of surface bacilli. If it is admitted that the germs giving rise 
to the infection in the guinea-pig were within the tonsillar epithelium, 
we practically admit the major proposition, namely, that the tonsils are, 
or may become, under favorable conditions, the portals of systemic or 
circumscribed infections in the contiguous glands and organs. In many 
instances this is also shown by the caseation or the suppuration which 
takes place in the tonsils. 

The facility with which the invasion of pathogenic microorganisms 
is accomplished through the tonsils depends upon the following factors: 

(a) The virulency of the invading microorganisms. 

(b) The pathogenicity of the microorganisms. 

(c) The general health of the patient. 

(d) The existence or the absence of the strumous diathesis. 

(e) The condition of the epithelium of the mucous membrane cover- 
ing the tonsillar crypts, and the condition of the tonsillar tissue. 

Piera has shown that bacteria are much more readily absorbed by 
the tonsils than is the coloring matter with which Good ale and Jona- 
than Wright experimented. Jonathan Wright, on the contrary, found 
the coloring matter to be more quickly absorbed than the bacteria 
(see p. 385). 

According to Piera, the germs pass into the interior of the tonsil, 
while the coloring matter is absorbed in the clefts of the lacunar epi- 
thelium. He also found that the pathogenic germs were more readily 
absorbed than the non-pathogenic, and that healthy tonsils absorb 
better than the fibrous. He does not intend to convey the idea, however, 
that healthy tonsils are a menace to the system, for, on the contrary, 
they have a protective function. If the healthy tonsil readily absorbs 
the pathogenic germs, it also has the power of destroying them. 

It has been thought that the tonsils are vestigial organs, which once 
had a function that is now more or less obsolete. Packard has called 
attention to the fact that tonsils have been traced in the lower animals 
from the reptiles up to man; and that they are more complex in man, and 
cannot, therefore, be said to be vestiges. On this subject, W r atson Wil- 
liams says that if the tonsils are in some measure a protection against 



. THE TONSILS AS PORTALS OF INFECTION 381 

the invasion of microorganisms, their protective power is limited, and 
when this limit is passed, they are a positive source of danger. The crypts 
and fissures of the tonsils may become " traps " for microbes, and the 
peculiar anatomical arrangement of their investing epithelium, described 
by Stohr, opens the gates to their invasion into the tissues of the tonsil, 
whence through the lymphatic channels and vessels they may gain an 
entrance into the system. 

Williams also refers to the researches by von Babes, wherein he proves 
that in pulmonary gangrene the infection may enter through the tonsils 
as well as through the bronchi. He also says, primary tuberculosis of 
the tonsils is less rare than is generally believed, and the failure of the 
faucial tonsils to arrest the development of the bacilli results in tuber- 
culosis of the cervical glands, so commonly observed in weakly children. 

It has long been held that rheumatic fever has its origin in infection 
through the tonsils. Clinical observation certainly supports this view, as 
acute articular rheumatism is commonly observed following an attack 
of acute tonsillitis. 

Dawson advances the ingenious theory that scarlet fever has its pri- 
mary lesion in the tonsils. Whether or not this view will be supported by 
future observations remains to be seen. It has been shown by Kocher 
that acute suppurative osteomyelitis may be due to an infection by the 
same route. 

Acute tonsillitis may be due to pneumococci, streptococci, and staphy- 
lococci, which are almost constantly present in the crypts of the tonsils. 

Wright and Walsham have failed to find the tuberculous process in 
removed tonsils, but this does not necessarily prove that they are not 
pathways of infection. I have already shown that the tuberculous 
infection may exist in a latent form; that is, the bacilli may be present 
within the follicles without giving rise to distinct histological changes. 
By the term follicles is not meant the crypts or lacunae, but the lymphoid 
nodules. 

The lines of defence against microbic invasions through the upper 
respiratory tract may be classified as follows: 

(a) The mucous secretions are regarded as having in some degree 
bactericidal properties, as they are rich in leukocytes. 

(b) The epithelial covering of the mucous membrane of the upper 
respiratory tract is a mechanical barrier. 

(c) The lymphatic tissue composing Waldeyer's ring (tonsillar ring). 

(d) The cervical lymphatic glands. 

(e) The bronchial lymphatic- glands. 

(J) The endothelial lining of the bloodvessels. 

(g) The endothelial lining of the lymphvessels. 

(K) The serum of the circulating blood. 

(i) The leukocytes in the circulation. 

It will be seen by the foregoing that the system is pretty well guarded 
against the invasion of pathogenic microorganisms. Should the first 
or the second barrier be overcome, the remaining ones are still ready 
to bar the further progress of the morbific bacteria. 



382 THE PHARYNX AND FAUCES 

In tuberculous infection of the cervical lymphatic glands the germs 
excite the reaction of inflammation, as shown by the enlargement of the 
glands. Under favorable conditions they are harmless on account of 
the phagocytic action in the leukocytes, which Stohr has shown are 
thrown out from the clefts in the epithelial covering of the crypts. 

Acute endocarditis, septic thrombophlebitis, and pyemic infarcts of the 
lungs have also been shown to be due to the absorption of microorganisms 
through the lymphatic ring. 

Recapitulation. — (a) Tuberculous tonsils have been found in subjects 
who died of tuberculosis. 

(b) Some observers have failed to find the tuberculous process in 
tonsils and adenoids removed from living patients, while others have 
been able to demonstrate it. 

(c) Primary tuberculosis of the tonsils, while not common, cannot be 
said to be rare. 

(d) Secondary tuberculosis of the tonsils has been demonstrated. 

(e) Latent tuberculosis may exist in tonsils and adenoids without 
presenting distinctive clinical signs. 

(/) The removal of tonsils and adenoids is sometimes followed by 
pulmonary tuberculosis. (This is doubtless a mere coincidence.) 

(g) There are several barriers to the invasion of pathogenic micro- 
organisms into the system. 

(h) The invasion of the pathogenic microorganisms is promoted by the 
virulency of the germ, and by certain local and constitutional conditions. 

(i) The tonsil is a barrier against the invasion of microorganisms, 
its power in this capacity being limited by the age of the patient and the 
condition of the tonsil. 

(j) Rheumatic fever, acute endocarditis, septic thrombophlebitis, 
pulmonary gangrene, and other infective conditions have their initial 
lesions in the tonsils. 

Practical Applications. 1 — In view of the facility with which micro- 
organisms, especially of the pathogenic type, gain entrance into the 
system through the tonsils, it becomes necessary under certain conditions 
to remove the tonsils in their entirety. 

I have seen cases in which repeated attacks of acute follicular tonsillitis 
and concurrent cervical lymphadenitis had taken place. After tonsil- 
lectomy, i. e., the complete removal of the tonsils, the tonsillitis neces- 
sarily ceased to recur, and there was no further recurrence of the lymph- 
adenitis. It may be logically concluded that the diseased tonsils acted as 
a permanent incubator for the streptococci and the staphylococci, and 
the incubator being removed, the cervical lymphadenitis disappeared. 

When a latent tuberculous process is present in the tonsils, the cervical 
glands are infected, and give rise to repeated enlargement and caseous 
degeneration of the glands. After the complete ablation of the tonsils, 
including the capsule, great improvement of the glandular disease should 
occur. While it may not always be advisable to perform tonsillectomy, 
it is usually advantageous to do so in those cases in which the cervical 
glands are enlarged. 



CLINICAL ANATOMY OF THE TONSIL 383 

It is also advisable to perform complete ablation when there is a tubercu- 
lous process in the tonsils with an incipient or latent involvement of the 
lungs. I have removed tonsils in this condition with the most satis- 
factory results. 

Singers and public speakers with a troublesome subacute laryngitis, 
and whose tonsils are small and fibrous, or enlarged, may be benefited 
by the complete removal of the tonsils, whereby a possible source of 
irritation to the larynx through the absorption of microorganisms and 
septic matter is removed. 



CLINICAL ANATOMY OF THE TONSIL 

The tonsil is situated in the sinus tonsillaris between the faucial pillars, 
and has its origin in an invagination of the hypoblast at this point. Later 
the depression thus formed is subdivided into several compartments 
which become the permanent crypts of the tonsil. Lymphoid tissue 
is deposited around the crypts, and thus the tonsillar mass is built up. 
The inner or exposed surface, including the cryptic depressions, is covered 
with mucous membrane, while the outer or hidden surface is covered 
by a fibrous capsule. 

According to Landois and Stirling, the development of the faucial 
tonsil is most easily studied in the rabbit, where the single primary 
crypt generally remains without branches through life, and there the 
tonsil first appears in embryos f inch long (occipitosacral measure- 
ment), or of about twelve days as a shallow epithelial fold whose apex 
points directly backward into the connective tissue concentrically con- 
densed around the pharynx. At this stage there is no infiltration of 
the leukocytes in the connective tissue around the crypt, and it is not 
until the embryos are about twenty-one days old (l T 3 g- inches long) that 
the leukocytic infiltration becomes evident. The crypt has then become 
much deeper and broader, and by its ingrowth has produced a condensa- 
tion of the connective tissues at right angles to the original peripharyngeal 
condensation, as well as a great increase in the number of capillary 
bloodvessels. From this stage the elongation of the crypt, the condensa- 
tion of the connective tissue, the increase in the number of bloodvessels, 
and the amount of leukocytic infiltration go on pari passu until the 
adult condition is reached. As soon as the leukocytes appear in numbers 
in the submucous tissue, they proceed to escape through the epithelium, 
as Stohr has described. 

In the fetus of the pig, the condensation of the connective tissue, 
especially at the apex of the tonsillar crypts, and the consequent massing 
of leukocytes, mainly at these points, is particularly well shown. 

In the human fetus the process is the same, though complicated by 
the early ramification of the original epithelial crypt and the appearance 
of fresh ones. The crypts become so deep that the cells from the surface 
layers of their epithelium cannot at once be thrown off into the mouth, 
and remain as a concentrically arranged mass of degenerated cornified 



384 THE PHARYNX AND FAUCES 

cells filling up the lumen of the crypt ; this mass is ultimately forced out 
by the vis a tergo of the leukocytes emigrating through the epithelium. 
It will at once be seen how closely this resembles the formation of the 
concentric corpuscles of the thymus. 

The prime factor in the formation of the tonsils is the epithelial 
ingrowth, which partly mechanically compresses the meshes of the 
connective tissue, and partly causes proliferation of the connective cells 
and vessels by the slight irritation it produces, thereby making it easier 
fcr the leukocytes to escape from the thin- walled capillaries and veno- 
capillaries so formed, and, when they have escaped, causing them to be 
detained in the finely meshed connective tissue longer than in other 
situations. As the leukocytes are well supplied with nutriment, they 
divide by mitosis in large numbers, as Flemming and his pupils first 
showed, and at a late stage in development (with great variations in 
individuals), "germ- centres" are formed, where a special arrangement 
of connective tissue and vessels favors the process of division. 

The lingual and pharyngeal tonsils develop in the same way as the 
faucial. His shows that all the tonsils arise- behind the membrana 
pharyngis, and, consequently, all these epithelial ingrowths pass into 
connective tissue already condensed around the primitive alimentary 
canal (G. L. Gulland.) 

It will be observed that the tonsil is an encapsulated organ, and that it 
is characterized by from eight to twenty crypts or tubular depressions. 
Many practitioners have confused the tonsil with the follicular tissue 
immediately surrounding it. So long as they were able to remove follic- 
ular tissue through the wound in the sinus tonsillaris, they thought they 
were removing tonsillar tissue. In this they were mistaken, as the 
lymphoid tissue immediately surrounding the tonsil is not encapsulated, 
nor is it characterized by cryptic depressions, and is therefore not tonsil 
tissue. 

The tonsil does not always completely fill the sinus tonsillaris, the 
unoccupied space above it being known as the supratonsillar fossa, 
into which several crypts usually open. 

The outer aspect of the tonsil is loosely attached to the superior con- 
strictor muscle of the pharynx, thus subjecting it to compression with 
every act of deglutition. The palatoglossus and palatopharyngeus 
muscles of the pillars also compress the tonsil. Grober cites authorities 
who claim that the compression of the muscles forces food and bacteria 
into the crypts, rather than out of them. 

Crypts. — The crypts are usually tubular and almost invariably 
extend the entire depth of the tonsil to the capsule on its outer surface. 
Some, however, are compound, i. e., they divide below the surface into 
two or more tubules. They are usually comparatively straight, though 
they may be tortuous in their course. I have examined many hundreds 
of tonsils which have been removed with their capsules intact, and have 
never found crypts that did not extend through the follicular tissue to the 
capsule. Those opening in the supratonsillar fossa usually extend down- 
ward and outward, whereas in the lower portion of the tonsil their direc- 



CLINICAL ANATOMY OF THE TONSIL 385 

tion is outward. The area occupied by the mouths of the supratonsillar 
crypts constitutes, according to Killian, the hilus of the tonsil. Clinically, 
the crypts seem to be the source of the greatest amount of local and con- 
stitutional disturbances, as they often become filled with food, tissue 
debris, and bacteria. This is especially true of those capped over by an 
overlying membrane, as the plica supratonsillaris, and the antero- 
inferior portion of the tonsil which is covered by the plica tonsillaris. 
The plica supratonsillaris does not, in all cases, enfold the hilus, or supra- 
tonsillar crypts, as the tonsil often fails to fill the supratonsillar space. 
In other instances, it closely hugs the upper end of the tonsil, thereby 
completely closing the mouths of these crypts. It is in these cases, 
particularly, that the contents of the crypts are retained. 

Reasoning from a mechanical point of view, one would reach the 
conclusion that the retention of the infected secretions must necessarily 
give rise to infectious inflammatory processes. Clinically, we know that 
this is not always true. The crypts are often found filled with food, 
tissue debris, and pathogenic bacteria, without any appreciable inflamma- 
tory reaction. Nevertheless, as I shall exemplify later, the mechanical 
closure of the crypts of the plica supratonsillaris and the plica tonsil- 
laris adds greatly to the tendency to inflammatory and other morbid 
local and general processes. 

It may be stated, as a general law in physiological pathology, that 
mechanical obstruction to the drainage of any secreting cavity tends to 
result in local morbid processes and in toxic or infectious manifestations 
in remote parts of the body. 

The Epithelium. — The free surface of the tonsil, including the crypts, 
is covered with stratified pavement epithelium, the deeper layers of 
which are columnar in type, while the superficial are pavement. Goodale 
has shown that certain coloring matter, when dusted in the crypts, is 
readily absorbed into the interior of the tonsil. He claims that the absorp- 
tion probably takes place through the interspaces between the cells. 
From this the inference might be made that bacteria are absorbed with 
equal facility. This conclusion does not, however, coincide with either 
physiological or clinical data. 

Jonathan Wright has shown that there is a vast difference in the 
absorptive power of the tonsil for dust and for bacteria. He intro- 
duced carmine powder and bacteria into the crypts of the tonsils and 
excised them in fifteen minutes. The microscope showed the carmine 
particles in great abundance beneath the epithelium and within the inter- 
cellular spaces, whereas no bacteria were found beneath the surface. He 
also observed that the carmine dust remaining on the outside of the tonsil 
was easily washed away, while the bacteria were more difficult to remove. 
The adherence of the bacteria to the live animal membrane and their 
failure to pass through it he ascribed to the viscosity of the bacteria, a 
biomechanical property of microorganisms. The mechanical affinity 
existing between the bacteria and a living mucous membrane he consid- 
ered as one of their defensive and offensive properties of a biomechanical 
kind, as distinguished from their biochemical products, the toxin and 
25 



386 THE PHARYNX AND FAUCES 

endotoxin. Dust or carmine powder does not possess this adhesive 
property, hence it is readily absorbed, whereas the bacteria are not. 

We know, however, from abundant clinical experience, that there are 
conditions under which the bacteria are absorbed through the cryptic 
epithelium in sufficient numbers to excite marked local and constitutional 
disturbances. Apparently, the adhesive property of the bacteria has been 
overcome, or the toxin of the microorganisms within the crypts has con- 
verted the live epithelium into inert matter, through which it readily 
passes. Wright says from the experiments of Goodale and others 
with colored granules, and from his own observations of dust particles 
passing the epithelial layer in health, and bacteria passing it in dis- 
ease, it is evidence that there must be something beyond mechanical 
obstruction which, under ordinary conditions of health, keeps the tissue 
beneath the epithelium free of bacterial life, which swarms in some of 
the crypts on the outer side of the epithelial cells. Hitherto the revela- 
tions of the antitoxic power of the blood sera have been insufficient to 
explain the problem. That explains the nullification of the toxic power 
of the pathogenic germ after it passes within the tissues, but it does not 
explain immunity from infection — to translate literally, the freedom 
from the carrying in of the germ. It seems probable from experimenta- 
tion with various forms of protoplasm that the animal organism evolves 
defensive properties to destroy by lysis, when the system through lack 
of excretory power becomes embarrassed by their presence. 

Wright also says that bacterial protoplasms may excite bacterio- 
lytic ferments in the epithelial cells, a property heretofore referred by 
Metchnikoff to the leukocytes only. In these ways he attempts to 
show the existence of equilibrium between immunity and infection. 
A lack of balance or equilibrium is effected by a loss of local tonicity 
or health, and infection then takes place. 

In the epithelial lining of the crypts we find, therefore, the following 
properties : 

(a) A biomechanical resistance to the invasion of the microorganisms, 
viscosity. 

(b) A biochemical destruction or taming of the microorganisms in 
the crypts through the agency of a ferment thrown out by the epithelium 
under the stimulus of the retained bacteria. This process is known 
as bacteriolysis. 

As long as the epithelium of the crypts is in a state of tonicity or health, 
an equilibrium between immunity and infection is maintained. When 
the cellular tonicity is impaired, the equilibrium between immunity 
and infection is lost and infection occurs. When the crypts are closed 
by the plica supratonsillaris and the plica tonsillaris, or by concretions 
in the mouths of the crypts, a very active warfare between the retained 
microorganisms and the epithelial cells is begun. The cells throw out 
a poisonous ferment, whereas the bacteria throw off a toxin for the pur- 
pose of impairing the tonicity of the epithelium. If the siege is continued 
sufficiently long, the cells give way, and the infectious host penetrates 
the epithelial barrier and enters the deeper tissues of the tonsil. 



CLINICAL ANATOMY OF THE TONSIL 387 

Sinus Tonsillaris. — The anterior pillar contains the palatoglossus 
muscle and forms the anterior boundary, whereas the posterior pillar 
contains the palatopharyngeus muscle and forms the posterior boundary 
of the sinus. The pillars meet above to unite with the soft palate. In- 
feriorly they diverge and enter into the tissues at the base of the tongue 
and the lateral wall of the pharynx respectively. The outer wall of the 
sinus tonsillaris is composed of the superior constrictor muscle of the 
pharynx. The sinus tonsillaris is, therefore, a triangular depression on 
the lateral wall of the fauces which partially envelops the tonsil. 

My clinical observations show that the tonsil is loosely attached in 
the sinus; that is, the so-called adhesions are not present. The extent 
of the attachment varies in different subjects. Patterson has shown 
that the supratonsillar fossa may extend downward so as to admit a 
bent probe between the outer side of the tonsil and the superior con- 
strictor muscle of the pharynx, as far as the inner surface of the lower 
jaw. Even when the attachment is general, it is not usually so firm as 
to greatly interfere with the enucleation of the tonsil. The "adhesion" 
to the anterior pillar so often spoken of is, in my opinion, a myth. It 
is true that the tonsil has an anatomical connection with the anterior 
pillar, but the union is not of that firm, fibrous nature usually implied 
by the term. Indeed, the term " adhesion" is often used in reference to 
the plica tonsillaris which covers the antero-inferior portion of the tonsil, 
and which is often attached to the tonsil at its inferior extremity. One 
writer even speaks of the plica triangularis as an hypertrophy of the 
anterior pillar, whereas, in fact, it is an embryological structure, which 
in some of the lower animals develops into the tonsil itself. 

The anterior limit of the sinus tonsillaris often extends well under the 
anterior pillar, thus concealing a large portion of the tonsil. The outline 
of the tonsil may be readily determined by digital examination or by 
seizing it with the forceps and drawing it toward the median line of the 
throat. When thus drawn the anterior shoulder of the tonsil may be 
seen outlined beneath the anterior pillar, and if still more forcibly drawn 
inward, the body of the tonsil slips from underneath the pillar, thus 
showing that it is not markedly adherent, but that, on the contrary, it is 
loosely attached and by proper procedures may be readily enucleated. 

Lymphatics. — The relation of the tonsil to the lymphatic vessels 
is somewhat different from that which exists between the lymphatic 
glands and vessels. The difference in the relationship consists in the fact 
that the lymphatic vessels have their origin in the tonsil, whereas they 
pass through the lymphatic glands. George B. Wood says the tonsils 
do not have afferent lymphatic vessels. The question of chief clinical 
importance is the course and termination of the tonsillar lymphatic 
vessels which drain into the deep cervical chain underneath the sterno- 
cleidomastoid muscle, from thence to the thoracic glands, and finally 
into the thoracic duct. By this route infection is carried to all parts of 
the body. The tonsil, under certain conditions, being peculiarly sus- 
ceptible to infection, becomes, therefore, the atrium of infection for a 
great variety of diseases extraneous to itself. Literature is rich with 
clinical reports of diseases illustrating this fact (Fig. 262). 



388 



THE PHARYNX AND FAUCES 



In reference to the tonsil as the portal of infection in tuberculous 
processes, it is generally admitted that this often takes place through the 
tonsil, and extends thence through the lymphatics of the deep cervical 
chain on into the thorax. It then passes through the hilus of the lung 
into the visceral pulmonary lymphatics. The apex of the right lung is 
the most frequent seat for the inception of the pulmonary tuberculous 
disease. This has, heretofore, been attributed to the fact that this area 
is less directly in line with the respiratory air current, and that this 
portion of the lung has less motion than other portions of either lung. 
It forms, therefore, a peculiarly favorable location for the development 
of the tubercle bacillus. 

Fig. 262 



ADEN01D5 




The lymphatic glands and vessels of the neck which drain the teeth, tonsils, adenoids, pharynx, 

and mastoid region. 

Dr. J. Grober has questioned the existence of this route of pulmonary 
infection, or at least he has advanced a rival hypothetical explanation, 
based upon a series of experiments upon lower animals. He reports the 
following three suggestive experiments out of a total of twenty-eight: 
_ First experiment, September 16, 1902. A young rabbit was anesthe- 
tized by ether and 1 c.c. of a sterilized emulsion of black Chinese paint 
injected into the left tonsil. 

September 23, 1902, the autopsy showed black particles in the blood. 



CLINICAL ANATOMY OF THE TONSIL 389 

Behind the left tonsil there was a mass composed of the coloring matter 
and leukocytes. The lymph glands on the left side of the neck, as far as 
the upper border of the thyroid cartilage, were stained black. The micro- 
scope demonstrated that the lymph vessels were filled with free coloring 
matter, as well as leukocytes which inclosed small particles of pigment. 

The glands and lymph vessels were fairly packed with the coloring 
matter. Beyond the zone of the lymph glands and vessels little coloring 
matter was found. 

Second experiment. A small dog was narcotized by morphine injec- 
tions. Six and one-half c.c. of the sterilized emulsion of black pigment 
was injected into the tonsil. 

The autopsy, after complete exsanguination, showed the following 
conditions: Very little coloring matter in the leukocytes, none being free 
in the blood. The tonsil and the loose connective tissue containing the 
afferent lymphatic vessels of the tonsil were of a deep black color. 

Along the muscles of the neck, as far as the hyoid bone and to the 
median line, there were streaks of pigment. The pigmented area also 
spread downward below the hyoid bone, where it extended 1 cm. beyond 
the median line. The coloring matter was traced to the bony opening 
of the thorax and to the parietal pleura, which, when stripped off and 
examined by transmitted light, showed the black pigmentation. The 
lymph vessels of the paratracheal connective tissue and of the esophagus, 
as far as 2 or 3 cm. above the bifurcation of the trachea, were also colored, 
whereas on the left or uninjected side no such phenomenon was found. 
All the lymph glands on the lateral wall of the pharynx, hyoid bone, 
larynx, along the deep vessels of the neck and supraclavicular fossa 
on the right side were black. The parietal pleura at the apex showed 
an exudate, but no adhesion to the visceral pleura. 

The microscope showed that in all the above-mentioned organs there 
were no other changes. In the glands the coloring matter occupied the 
paravascular spaces. In the lymph vessels between the supraclavicular 
glands and the parietal pleura of the apex there was a large number 
of leukocytes which were filled with coloring matter. Free coloring 
matter was also present in this region. In the apex of the lung there 
were no signs of an inflammatory reaction. The coloring matter here 
seemed to be freely deposited within the connective tissue. In the 
above-mentioned second experiment there was coloring matter in the 
leukocytes. 

Third experiment, April 4, 1903. A small dog was placed under 
morphine narcosis and 5 c.c. of coloring matter injected into the tonsil. 
April 13, the same experiment was performed on the opposite side. 

May 10, the autopsy, after exsanguination, showed a large amount of 
coloring matter free in the blood ; the leukocytes, the tonsil and connec- 
tive tissue, and the connective tissue of the neck on both sides along the 
larynx to the aperture of the thorax were colored symmetrically. The 
lymphatic glands along the large bloodvessels, as well as those in the 
supraclavicular region, were deeply stained. The coloring matter was 
also found within the lymphatic vessels and in the paravascular spaces. 



390 THE PHARYNX AND FAUCES 

A fibrous exudate was found in the apices of both lungs, thus forming a 
bridge of inflammatory material from the parietal to the visceral pleura. 
The coloring matter was also present in the exudate. The microscopic 
appearance of the apices presented a light grayish coloration. The 
glands in the mediastinum were stained on the left side, as were also the 
bronchial glands. In the left lung there were three other small fibrinous 
exudates in which the coloring matter was present. 

From these experiments, Grober builds the hypothesis that tuberculous 
infection of the apex of the lung may take place via the deep lymphatic 
chain, the supraclavicular glands, and thence to the parietal lymphatic 
vessels where an inflammatory exudate is thrown across to the visceral 
pleura. The tubercle bacilli travel across this inflammatory bridge and 
enter the apex of the lung. 

While these experiments are not conclusive, they are interesting and 
open a field for further observations. 

Blood Supply. — The tonsillar artery, a branch of the facial, is 
the chief vessel to the tonsil, though the ascending palatine, another 
branch of the facial, sometimes takes its place. The tonsillar artery 
passes upward on the outer side of the superior constrictor muscle, 
through which it passes and gives off branches to the tonsil and soft 
palate. The ascending palatine, another branch of the facial, also sends 
branches through the superior constrictor muscle to the tonsil. The 
ascending pharyngeal also passes upward outside of the superior con- 
strictor, and when the ascending palatine artery is small, it gives 
off a tonsillar branch which is correspondingly larger. The dorsalis 
linguae, a branch of the lingual artery, ascends to the base of the tongue 
and sends branches to the tonsil and pillars of the fauces. The descend- 
ing or posterior palatine artery, a branch of the internal maxillary, 
supplies the tonsil and soft palate from above, forming anastomoses 
with the ascending palatine. The small meningeal artery sends more 
branches to the tonsils, though they are of minor importance. 

Clinical Application.— Without reviewing the literature, which is 
rich in reports of cases showing the tonsil to be the portal of infection 
for many diseases in remote parts of the body, I have attempted to 
show under what conditions it becomes the portal or atrium of infec- 
tion. Under conditions of local equilibrium or health of the epithe- 
lial lining of the tonsillar crypts, infection does not take place, whereas 
when the local equilibrium is lost, infection occurs. That the local equi- 
librium of the cryptic epithelium is frequently lost, is apparent to every 
clinician. In addition to the diseases arising through the tonsil as a 
portal of infection, there are those limited to, or having their focal centre 
in, the tonsil itself. Perhaps the strongest indictment against the tonsil 
is that it is often the atrium of infection in pulmonary tuberculosis. 
Whether the route of infection is via the deep lymphatics and the hilus 
of the lung, or the deep lymphatics and the parietal pleura at the apex, 
as shown by analogy in the experiments of Grober, is immaterial. The 
question of prime importance is, Do pulmonary or other types of tuber- 
culosis have their origin through the tonsil as a portal of infection? In 



CLINICAL ANATOMY OF THE TONSIL 391 

view of ruy own observations, and of others, I must answer in the affirma- 
tive. Just what percentage has not been fully determined. Various 
writers report that from 4 to 10 per cent, of tonsils (removed) show local 
tuberculous lesions, such as tubercle bacilli and giant cells. 

The structures of the tonsil which seem to favor infection are the 
crypts, especially those in the supratonsillar fossa and those covered 
by the plica tonsillaris. Wright has suggested that the imperfect drain- 
age of the crypt leads to the ultimate loss of tonicity (equilibrium) in 
the epithelial cells which line them, thereby opening the way to systemic 
infection through the tonsil. 

The question naturally presented at this juncture is, What is the 
rational method of procedure to protect the system from further infec- 
tion? The choice of remedial measures seems to lie between internal 
medication, local applications, and surgical interference. 

As to the first and second methods of treatment, it may be said that 
there are cases which may be satisfactorily treated by them; especially 
by relieving the distressing local inflammatory symptoms; indeed, many 
cases may be practically cured by such treatment. There are many 
others, however, in which such measures are wholly inadequate, either 
to relieve immediate symptoms or to ward off future attacks. In these 
cases we have usually resorted to some surgical procedure, such as open- 
ing the crypts and plunging the cautery point obliquely across them, 
decapitation (partial removal of the tonsil), and the complete removal of 
the tonsil. 

The literature shows a wide divergence of opinion as to what consti- 
tutes the best method of surgical treatment, although it shows that nearly 
all writers agree that some sort of surgical procedure is indicated. 

What does the anatomy indicate? It shows certain crypts so situated 
as to afford poor drainage of their contents, even though the superior 
constrictor, palatoglossus, and palatopharyngeus muscles compress the 
tonsil with each act of deglutition. This is especially true of those 
crypts which discharge into the supratonsillar fossa. KaurTmann has 
suggested that the supratonsillar crypts be opened with a sharp knife, 
and that the incised surface be painted with 5 to 20 per cent, trichloracetic 
acid. By thus opening the crypts their contents are drained. The 
applications of acid excite a violent inflammatory reaction which results 
in the contraction of the tissue of the tonsil. The process is often an 
extremely painful one, and may result in cellulitis and the formation of 
scar tissue. Furthermore, it does not always prevent further infection 
through the tonsil. It is, therefore, often necessary to repeat the incisions 
and applications of acid. 

The patient is entitled to immunity from tonsillar infection if it can 
be established without seriously jeopardizing either his health or life. 
When the tonsil becomes a well-established atrium of infection, the 
physical economy of the patient is constantly menaced by conditions 
ranging all the way from a follicular tonsillitis to endocarditis and pul- 
monary tuberculosis. . Measures should, therefore, be adopted which 
will insure future freedom from infection through the tonsil. 



302 THE PHARYNX AND FAUCES 

It has been shown by abundant clinical experience that cauterization 
of the lumen of the crypts or obliquely across them into the surrounding 
follicular tissue does not adequately meet the indications. 

The same is true of "decapitation," or partial removal of the tonsil. 
Decapitation leaves the deep and more diseased portion of the crypts, 
and, while it may afford some relief of the symptoms, it is often followed 
by recurrent infections and by the reformation of the tonsillar tissue. 

The complete removal of the tonsil with its capsule intact is, so far as 
I know, the only surgical procedure that guarantees immunity from 
infection through the sinus tonsillaris. 

The function of the tonsil and the effect of its complete removal upon 
the general condition of the patient must be considered; so, also, must 
the question of hemorrhage. In reference to the effect of the removal 
of the tonsil upon the general system, it may be said that there is little 
evidence that it has any deleterious result. Masini, however, believes 
that the tonsil has an internal secretion comparable with that given 
off by the suprarenal gland. He arrived at this conclusion after experi- 
ments with the aqueous extract of the tonsil, intravenous injections 
of which gave the same results as those obtained from the injection of 
suprarenal extract. 

The last word concerning the treatment of the tonsil cannot be spoken 
until its exact function is established. Clinically, there is little to show 
that its removal causes evil effects, whereas there is much evidence to 
show that good results, especially from its complete removal. 

I have attempted its complete removal with the capsule intact in 
about 5000 cases during the past ten years, and, barring one or two 
instances in which there was a temporary paresis of the palatopharyn- 
geus muscle, one case of cervical cellulitis, and a half-dozen moderately 
severe hemorrhages, I have seen no unfortunate result. The general 
health of many patients was greatly improved and recurrent septic 
inflammation within the sinus tonsillaris was eliminated. Recurrence 
of the tonsillar tissue has not taken place in a single instance. Should 
it grow again, this is almost prima facie evidence that the entire tonsil 
was not removed, nor have I seen a case in which the patient suffered 
from the loss of an "internal secretion," which some writers claim is 
produced by the tonsil, though they have never proved it. 

When the tonsil has been completely removed, with its fibrous 
envelope, the source of infection is removed. It is, of course, possible 
for the follicular tissue which surrounds the tonsil to become diseased, 
but this should be differentiated from tonsillar disease. When the 
tonsil is not removed with its capsule intact, it is difficult to determine 
whether it has been entirely removed ; and if a part of it is left, regenera- 
tion is likely to occur. The tonsil, if removed in its entirety, should show 
a distinctly defined mass of lymphoid tissue enveloped within a smooth, 
glistening, fibrous capsule on its outer, and with mucous membrane on 
its median, aspect. Lymphoid tissue which is not thus characterized is 
not tonsillar tissue. 

Hemorrhage. — The danger from hemorrhage is, perhaps, the greatest 



CLINICAL ANATOMY OF THE TONSIL 



393 



objection to the operation. Is this a real or an imaginary obstacle ? It 
is both in adults. It is real in that severe hemorrhage does occasionally 
occur in operations on the tonsils. It is imaginary as to the reputed 
frequency of its occurrence and the degree of danger attending it. A 
knowledge of the possible sources of hemorrhage will enable the operator 
to largely exclude its occurrence. Furthermore, there are certain matters 
in the technique of local anesthesia, and in the after-treatment which, 
if properly applied, will greatly reduce the frequency and severity of 
hemorrhage. Clinically, I have observed that the most frequent site 
of arterial hemorrhage is at about the middle portion of the sinus tonsil- 
laris, where the tonsillar branch of the facial pierces the superior con- 
strictor muscle of the pharynx. Other points of hemorrhage are usually 
limited to the inferior portion of the sinus tonsillaris, where the tonsillar 
venous plexus is located, and to the anterior and posterior pillars. 



Fig. 263 




a, subdivisions of the tonsillar artery; b, superior constrictor muscle of the pharynx; c, c, fibrous 
capsule of the tonsil; d, lymph follicles or substance of the tonsil; e, plica supratonsillaris; f, supra- 
tonsillar fossa. 

In another part of this chapter I have referred to the fact that three 
arteries, the tonsillar, the ascending palatine, and the ascending pharyn- 
geal, pass upward on the outside of the superior constrictor muscle, which 
they pierce as they turn inward to ramify the tonsil and faucial pillars. 
Just before entering the tonsil they break up into several branches 
(Fig. 263). It is obvious that the smaller the branches cut during an 
operation, the less serious the hemorrhage. The clinical application of 
this fact is that if the arterial branches are severed as they enter the 



394 THE PHARYNX AND FAUCES 

capsule of the tonsil, the chance of hemorrhage is reduced to the mini- 
jnum; whereas, if they are severed on the outer aspect of the superior 
constrictor muscle before they are broken up into smaller branches, the 
danger from both primary and secondary hemorrhage is greatly in- 
creased. It may be said that the operator should not injure the superior 
constrictor muscle in this operation, and this is true. Indeed, if he 
thoroughly appreciates the clinical significance of the anatomy of the 
tonsillar region, he probably will not injure it. 

As to the anterior pillar, it should be borne in mind that there are 
arterial twigs coursing through it. The main trunks of the arterial 
branches are external to the palatoglossus muscle. Hence, it follows 
that in order to injure them, it is necessary either to pass the instrument 
behind the muscle or to include the musculature of the anterior pillar 
in the grasp of the tonsillotome, knife, blunt dissector, or scissors, and 
thus sever the muscle and vessels of the anterior pillar. The same 
statements may be made in reference to the posterior pillar. 

The technique should, therefore, be such as to avoid injuring the 
muscles bounding the sinus tonsillaris, namely, the superior constrictor 
of the pharynx, the palatoglossus and the palatopharyngeus muscles, for 
by such technique only the small branches of the tonsillar arteries are 
injured. 



CHAPTEE XXII 

INFLAMMATORY DISEASES OF THE TONSIL 

General Considerations. — The inflammatory diseases of the tonsils 
are usually subdivided into various types, according to whether the 
process is acute or chronic, and is limited to the crypts or extends to 
the substance or parenchyma of the tonsil. As a matter of fact, this 
classification is somewhat artificial, as it is now well established that all, 
or nearly all, inflammations of the tonsil are due to infection through the 
epithelium of the crypts. The manifestations may be acute or chronic 
in type; it may appear as an acute or chronic lacunar inflammation, with 
the typical exudate at the mouths of the lacunae or crypts; or it may be 
manifested in the form of a parenchymatous inflammation, in which the 
whole substance of the tonsil is involved. Inflammations of the tonsils 
are not surrounded by any profound mysteries other than those of a 
biochemical nature, which are common to all inflammatory processes. 
The fact of chief importance is that in all types of tonsillar inflammation 
there is a lesion of the epithelium which lines the crypts, and that some 
form of pathogenic bacteria has penetrated it. The determination of 
the type and virulence of the microorganisms is of even greater importance 
than the determination of the type of tonsillar inflammation under the 
older classification. The bacteriological findings at least afford some 
useful information as to the virulence of the infecting microorganism, 
and, therefore, influence the mode of treatment to a certain extent. If the 
virulence is marked, immediate surgical procedure is contraindicated ; 
indeed, the presence of an acute inflammation would of itself constitute 
a contraindication to operative interference. 

Much remains to be learned concerning inflammations of the tonsils. 
It may still be questioned whether it is good practice to remove tonsils 
in the wholesale manner now in vogue. The function of the tonsil in 
a child and in an adult is still an open question. When does its function 
cease or become so altered by disease as to justify its removal? Should 
the tonsil be partially or completely removed? When removed, what 
organ performs its functions ? These and other questions are not fully 
answered. We know from clinical experience that when a tonsil shows 
a tendency to become the seat of recurrent inflammations the patient's 
health and life are conserved by its entire removal. Are there other 
methods of treatment that will better conserve the health and life of the 
patient? It is doubtful, though this is still an open question. The 
removal of the debris from the crypts, from time to time, would no doubt 
avert many acute exacerbations; the topical application of solutions of 
silver might also prevent acute manifestations, but in the long run such 

(395) 



396 THE PHARYNX AND FAUCES 

methods of procedure must fail. The complete removal of the tonsil 
during a quiescent period must always succeed in preventing inflam- 
mation of the tonsil for all time to come. Will a tonsil thus removed 
recur? Never, if it is completely removed. Can it be removed by dis- 
section with its capsule intact? Yes; with the most happy results. 



ACUTE LACUNAR TONSILLITIS 

Synonyms. — Acute follicular tonsillitis; infective tonsillitis, cryptic 
tonsillitis. 

Etiology. — The chief causes of this and other forms of tonsillitis are. 
the local impairment of the epithelium of the crypts and the invasion 
of certain pathogenic bacteria, as has been shown in the Tonsils as 
Portals of Infection and the Clinical Anatomy of the Tonsil. There are 
other factors which enter the etiology, and they will be discussed in 
the following analysis : 

Local Lesion of the Tonsil. — As shown by Goodale and Wright 
the crypts of the tonsil are the seat of absorption for dust and micro- 
organisms, whereas the surr^ice epithelium of the tonsil has but little 
part in this process. They have shown that dust, as carmine powder, is 
readily absorbed through the healthy epithelium of the crypts, whereas 
bacteria are not. Bacteria are only absorbed through dead or impaired 
cryptic epithelium. Hence, the prime requisite for tonsillar infection 
is an impairment of the cryptal epithelium. This condition may be 
brought about by the retention of exfoliated epithelium and other 
debris in the crypts of the tonsil. The retention is formed by the con- 
striction of the mouths of crypts from previous inflammation, and by the 
plica supratonsillaris and the plica tonsillaris, which cover the mouths 
of some of the crypts in such a manner as to prevent the expulsion 
of their contents. The toxin thrown out by the imprisoned micro- 
organisms causes the death of the cryptal epithelium, and thus opens 
the way for the invasion of the microorganisms into the tonsil and the 
general lymphatic and circulatory systems; hence, the constitutional 
symptoms in this disease. 

Bacteriology. — The bacteriology of acute tonsillitis embraces sev- 
eral pathogenic microorganisms, including the Streptococcus pyogenes, 
the Staphylococcus aureus and albus, the pneumococcus, and the 
leptothrix. 

Age. — The disease is most common in young adults between the 
twentieth and thirtieth years of life. It is also common in children, and 
more rare after the fortieth year of life. 

Catching Cold. — Tonsillitis is frequently the immediate result of catch- 
ing cold, though this is but one way in which the resistance may be 
lowered, which favors the growth of the pathogenic bacteria. 

Surgical Trauma. — The inflammations following surgical procedures 
in the nose and epipharynx frequently extend to the tonsil, and are of 
bacterial origin. 



PLATE XI 



I'JiLffF 




Acute Lacunar Tonsillitis 

This disease may usually be cured by one application of a 9C per cent, 
solution of the nitrate of silver. 



ACUTE LACUNAR TONSILLITIS 397 

Specific Fevers. — Tonsillitis is often associated with specific fevers, 
such as scarlatina and diphtheria, and is of bacterial origin. 

Pathology. — In acute lacunar tonsillitis the tonsil is swollen, though 
the chief changes occur in the crypts, where there is an accumulation of 
leukocytes and dead epithelial cells intermixed with pathogenic bacteria. 
The transudation of leukocytes occurs chiefly through the cryptic mem- 
brane rather than the surface mucosa. The accumulated material in 
the crypts or lacunae is sometimes entangled in a fibrous exudate or 
pseudomembrane, though the pseudomembrane is not always present. 

Symptoms. --The Subjective Symptoms. — In this, as in other acute 
infectious processes, the onset is sudden and is attended by malaise and 
fever. Chilly sensations or light rigors may mark the attack. The tem- 
perature gradually rises until the end of the first to the third day to 
102° or 103°, and in young children it may rise as high as 104° to 105°. 
The febrile movement is accompanied by soreness upon swallowing, 
which as the disease progresses may become quite painful. The inflam- 
mation extends to the pharyngeal mucous membrane, and even, in 
exceptional cases, to the Eustachian tube and the middle ear. There 
may be pain in the ear through reflex sources without actual inflam- 
mation in the tympanum. Tinnitis may also be present. The gland 
under the angle of the jaw is usually swollen and tender, as it is in a 
state of great physiological activity, in its attempt to check the invading 
host of bacteria which has passed through the impaired epithelial barrier 
in the crypts of the tonsil. The swollen condition of the tonsil and 
surrounding muscles renders rotary motions of the head somewhat pain- 
ful. The same condition also renders articulation and phonation imper- 
fect, the voice being thick and indistinct. The tongue is coated with a 
yellowish-brown fur, and the breath is fetid and offensive. Transient 
albuminuria is sometimes present, especially if the attack is severe and 
prolonged. Casts may also be found in the urine. Such a condition is 
common to all acute infectious processes in any part of the body, and do 
not necessarily point to grave results. 

The acute symptoms rarely extend beyond the third, fourth, or the 
fifth day. The febrile movement and the swelling and soreness rapidly 
subside until the temperature is normal and the act of deglutition and 
the rotation of the head may be performed with comfort to the patient. 
The patient, though convalescent, is often left in a very weakened 
condition. 

The Objective Symptoms. — At the onset the tonsils are swollen and red, 
while the crypts may not present the characteristic yellowish furred 
appearance, especially in the central and posterior aspects of the tonsil. 
The pharyngeal mucosa and the pillars of the fauces are usually redder 
than normal. At a later period, the tonsil and pharynx are still more 
swollen, and a creamy discharge is seen extruding from the mouths of 
one or more of the crypts. The patches are not usually true mem- 
branous products, as found in pseudomembranous and diphtheritic 
inflammations, but are the secretions and debris which completely till 
the crypts. (See Plate XL) 



398 THE PHARYNX AND FAUCES 

Occasionally a fibrinous exudate is admixed with the debris, which 
gives it some of the characteristics of an inflammatory membrane. 
The protruding secretion and debris are easily wiped away, in contra- 
distinction to the diphtheritic membrane, which is closely adherent to 
the epithelium. 

I have seen cases of diphtheria which closely resembled acute follicular 
tonsillitis, inasmuch as the membrane was loosely attached, on account 
of the solvent action of antitoxin administered eighteen to twenty-four 
hours previously. 

Pharyngeal and lingual tonsils are usually simultaneously inflamed 
with the faucial tonsil, and the yellowish exudate or debris peculiar to the 
faucial tonsil is found in the shallow crypts of the pharyngeal tonsil and 
still more shallow depressions of the lingual tonsil. The debris is similar 
in composition to that found in the crypts of the faucial tonsils. If the 
febrile symptoms continue after the faucial tonsil appears to be well, 
the pharyngeal and lingual tonsils should be examined with a laryngeal 
mirror for evidences of inflammatory processes. 

Complications and Sequelae. — Complications and sequela? are com- 
paratively rare. The case usually ends favorably in seven or eight days, 
though it may cause acute articular rheumatism, endocarditis (I know 
of two such cases), and other affections remote from the tonsils. Under 
appropriate treatment the duration of the disease is often much shorter 
than this; one application of a strong aqueous solution of silver nitrate 
often terminates the disease within a few hours. Occasionally, when 
only one tonsil is diseased, the other is affected at the close of the first 
attack. When this is the case the febrile and other symptoms are repeated. 
The follicular inflammation is rarely followed by a phlegmonous inflam- 
mation of the tonsil or of the peritonsillar tissue (quinsy). The cervical 
glands, beginning with the one under the angle of the jaw, may sup- 
purate. Purulent otitis media, pericarditis, pleuritis, erythema nodosum, 
and erythema multiforme have been reported as sequela? of acute tonsil- 
litis. Transient albuminuria is a rather common complication. 

Diagnosis. — The following table will aid in the differential diagnosis 
between acute lacunar tonsillitis and diphtheria, although there are cases 
in which the differential points are obscure, and dependence must be 
placed upon the bacteriological findings- 

Acute lacunar tonsillitis. Diphtheria 

1 . Onset marked by sharp rise of tempera- 1 . Onset, rise more gradual. 

ture. 

2. Rapid, bounding pulse. 2. Slow, feeble pulse. 

3. Depression not marked. 3. Depression marked. 

4. Exudation limited to the tonsil, especially 4. Exudation extends beyond the tonsils and 

the mouths of the crypts. is not limited to the crypts. 

5. Exudate not adherent. 5. Exudate closely adherent. 

6. Exudate soft and friable. 6. Exudate firm and leathery. 

7. Exudate not distinctly membranous. 7. Exudate membranous and may be re- 

moved in strips. 

8. Swollen glands uncommon except in severe 8. Swollen glands common even in mild 

cases. cases. 

9. Albuminuria occasionally present. 9. Albuminuria common. 

10. Klebs-Loeffler bacillus absent. 10. Klebs-Loeffler bacillus present. 



ACUTE LACUNAR TONSILLITIS 399 

I have seen cases in which repeated examinations failed to show the 
Klebs-Loeffler bacilli, which were finally shown at subsequent exami- 
nations. Absolute dependence must not, therefore, be placed upon 
negative microscopic findings; if, however, the Klebs-Loeffler bacilli are 
found, the case should be pronounced diphtheria, even though the clinical 
phenomena do not corroborate the microscopic findings. 

Treatment. — This type of tonsillitis is more amenable to treatment 
than any other. One application of a 50 to 90 per cent, solution of nitrate 
of silver, if applied locally during the first twenty-four hours of the 
disease, will in nearly every instance abort the attack. I have repeat- 
edly used silver in this way, and upon the following day the disease 
is under complete control. A second application is rarely required. 
The febrile and other symptoms rapidly decline and convalescence 
is quickly established. This may appear to be an overstatement of 
the facts, but it is in accordance with my experience. I have tried 
other remedies, but none of them have equalled the nitrate of silver. 
This strength of silver may appear to be caustic in action and unsuited 
for the treatment of acute tonsillar inflammation. As a matter of fact, 
it unites with the mucin so readily that its caustic action is greatly 
diminished before it reaches the mucous membrane. It coagulates the 
secretions and blanches the mucous membrane, thereby checking 
the inflammatory infiltration of the tissues. It also entangles the patho- 
genic bacteria in the albuminate of silver and prevents further activity on 
their part. It appeals to me as an ideal remedy in the early stage of 
the disease, and is worthy of extended trial. 

In applying silver to the tonsil the excess of fluid should be squeezed 
from the cotton-wound applicator to prevent it trickling to the larynx, 
where it will produce violent spasm of the intrinsic muscles. The silver 
salts are not well tolerated by the motor nerves and muscles of the 
larynx, and severe suffocative symptoms may be produced by inat- 
tention to the technique of its application. I have seen cases in which 
severe cyanosis resulted from this cause. A little attention on the part 
of the physician will obviate this distressing occurrence. Guaiacol, 
25 to 50 per cent, in olive oil, is the next most effective remedy. It 
should be applied locally two or three times daily for two days. The 
effect is very beneficial, though not so immediate as that of the nitrate 
of silver. It produces a hot, peppery sensation for about thirty seconds, 
followed by a sense of relief. 

The carbonate of guaiacol given internally in 5 grain doses every 
three hours exerts a very beneficial action upon the course of the disease. 

The tincture of the chloride of iron in eight parts of glycerin given in 
teaspoonful doses every two hours is another good remedy. 

The salicylate of sodium, the benzoate of sodium, and the chlorate of 
potash are also recommended, but the silver solution is so much superior 
to either of the other remedies mentioned that it should be used in nearly 
all cases to the exclusion of the other remedies. 

A laxative foljowed by a saline cathartic should be given early in the 
course of the disease. 



400 THE PHARYNX AND FAUCES 

If there is a history of repeated attacks of acute lacunar tonsillitis, 
the tonsils should be removed by complete dissection during the interval 
between the attacks. This procedure alone offers a considerable hope 
of permanent relief from the attacks and their more serious complications 
and sequelae. 

VINCENT'S ANGINA 1 

Synonyms. — Ulcerative tonsillitis; pseudomembranous angina. 

Etiology. — Since Vincent described a spirillum associated with a 
fusiform bacillus found in certain forms of ulcerative tonsillitis, the con- 
dition has been called Vincent's Angina. The disease is most frequently 
found in young persons, though it occurs often in those of middle and 
later life. A debilitated state of health, local irritative lesions in the 
mouth, such as decayed teeth, inflamed gums, and oral uncleanliness, 
favor the development of the disease, which is by no means an uncommon 
one. 

Pathology. — The lesions commonly involve one tonsil, usually at its 
upper part, may spread to the soft palate, the other tonsil, the pharynx, 
or the gums. It may even spread to the larynx or trachea, as in a case 
reported by Bruce. Farrel reported a case in a man, aged fifty years, 
in whom the lesion involved the tonsils, pharynx, and larynx. The mem- 
brane covering the patches is a pseudomembrane, and is formed by the 
necrosis of the superficial layers of the mucous membrane, not by exuda- 
tion. The patches are of a grayish-white color, surrounded by a red 
inflamed areola, but separated from each other by healthy tissue. On 
removal of the membrane, which is granular and cheesy in consistency, 
an ulcerative area is exposed, varying in extent and depth. The ulcer- 
ated areas bleed freely, and are soon covered by a new membrane. The 
ulceration at times is very destructive, destroying the whole or a portion 
of the tonsil, and invades healthy tissue. T. H. Halstead removed the 
tonsils from a young girl, aged twenty years, several weeks following 
the apparent cure of a slight attack of Vincent's angina. The wound 
became immediately infected, the pseudomembrane extending across 
the soft palate and uvula. The patient suffered very great dysphagia 
for three weeks, and some dyspnea for a few days. The uvula sloughed 
off, and there was deep ulceration of the soft palate. The characteristic 
fusiform bacillus and spirillum of Vincent were present throughout in 
large numbers. In one of my cases, a physician, aged thirty-eight years, 
the fusiform bacillus and spirillum were present, and the symptoms 
had been present for two months. The membrane covered the upper 
portion of the left tonsil and pillars of the fauces. It yielded in one month 
to the local applications of a 10 per cent, extract of silver solution. Iodine 
did not seem to affect the case favorably. Immediately after the cessa- 
tion of the symptoms, the tonsil was enucleated by dissection. After 
the lapse of three months there was no recurrence. 

i The author is indebted to Dr. T. H. Halstead for much of the data on Vincent's angina. 



VINCENT'S ANGINA 401 

The microscopic examination of a fresh smear taken directly from 
the ulcer, or a section of the pseudomembrane, stained with Loeffler's 
methyl blue or fuchsin, show fusiform bacilli, twice as long as wide, 
pointed at the ends, and with this a spirillum forming a network around 
the bacilli. The spirillum is 10 to 20 microns in length. This being the 
only fusiform bacillus occurring in the mouth, is readily recognized 
when found associated with the spirillum. As yet these bacteria have 
not been grown on any known culture media. 

Diagnosis. — The diagnosis is made positive by the discovery of the 
typical Vicent's bacteria, the fusiform bacillus and spirillum. Un- 
questionably many cases, occurring in both children and adults, 
suspected of being diphtheria, but in whom Loeffler's bacillus is not 
found, are cases of Vincent's angina. Such suspected cases, in whom 
the culture is negative for diphtheria, should be examined for Vincent's 
angina. The same may be said of doubtful cases of suspected syphilis, 
both in the secondary and tertiary stage. An examination of a smear 
would clear up the diagnosis. 

Differential Diagnosis. — The diseases usually confounded with it are 
diphtheria and syphilis. Many cases of what are called " ulcerative sore 
throat," gangrenous tonsillitis, are in reality Vincent's angina. 

Symptoms. — The usual symptoms are of a subacute, or mild tonsil- 
litis, headache, general malaise, chilly sensations, temperature varying 
from normal to 102.5°. There may be no constitutional disturbances, 
the patient complaining only of more or less pain in swallowing, or 
he may have discovered the yellowish patch on examining his throat 
with a mirror, because of a slight feeling of discomfort. Again, the 
symptoms are most violent, great pain in swallowing or talking, breath 
fetid, more or less gastric disturbance, submaxillary and cervical glands 
enlarged and tender. The ulcer may be single, or the membrane may 
spread like diphtheria and as rapidly. 

The disease is acute, subacute, and often becomes chronic, the ulcers 
persisting for weeks or months. One attack is likely to be followed, 
months or even a few years later, by a recurrence. 

Prognosis. — While most attacks are more or less mild, the patient 
suffering only local discomfort, the disease tends to persist for several 
weeks, and recurrence may occur at any time. Complications are seldom 
troublesome, and a fatal issue is not to be expected unless the larynx or 
trachea becomes invaded in a child. 

Treatment. — Local treatment is of most importance. The galvano- 
cautery and chemical cauterizing agents have been used without much 
success. The tincture of iodine applied to the ulcerated area several 
times a day, the applications being limited to the ulcer, is probably the 
best local agent for destroying the bacteria and promoting healing. 

A 10 per cent, solution of nitrate of silver and a 30 grain to 1 ounce 
solution of zinc sulphate are also recommended. Indeed, I have obtained 
better results with this remedy than with iodine. (See case cited under 
Pathology.) Mouth washes, such as Seiler's solution, or a solution of 
chlorate of potash, are advantageous. Most relief from the pain in 
26 



402 THE PHARYNX AND FAUCES 

swallowing will be obtained from the use of orthoform, in powder or 
tablet form. General tonic treatment is indicated. 

To prevent infecting others, drinking and eating utensils should be 
sterilized and kept separate. Sputum and mouth discharges should be 
burned. Following the attack, local disease of the mouth and teeth 
should be attended to, but operative work had best be postponed until 
making sure by the microscope of the absence of the specific bacteria. 



CHRONIC LACUNAR TONSILLITIS 

Definition. — Chronic lacunar tonsillitis is characterized by the pres- 
ence of caseous material composed of layers of desquamated epithe- 
lial cells enclosing cholesterin crystals, fatty matter, leukocytes, micro- 
organisms, and occasionally calcareous deposits. The masses vary in size 
from that of a grain of wheat to that of a small bean. The crypts most 
often involved are those which open into the supratonsillar fossa and 
those covered by the plica tonsillaris, for the reasons already given 
in the Clinical Anatomy of the Tonsil. The tonsil may or may not be 
hypertrophied, though it is generally in that condition. 

" Etiology. — One of the chief causes of the disease is the retention of 
the desquamated epithelium, bacteria, and debris in the crypts, which 
in turn is due in part to the anatomical barriers afforded by the plicae 
supratonsillaris and tonsillaris. In addition to this, there is a diseased 
condition of the epithelium lining the crypts, due to previous acute 
inflammations. This disease usually occurs in adults. 

Symptoms. — The subjective symptoms are not usually severe in 
character. The patient may complain of pain upon swallowing saliva, 
but not upon swallowing solid food (Ball). Neuralgic pains sometimes 
shoot toward the ear. Some patients have the sensation, lasting perhaps 
for only a minute or two, of a foreign body lodged in the tonsil. 

The objective symptoms are more marked and characteristic than 
the subjective ones. The patient coughs up the caseous masses, which 
have a fetid odor, and he consults a physician, who upon examination 
notes the fetid breath and the yellowish masses in the crypts of the 
tonsil. Upon exerting pressure upon the tonsil with a flat instrument 
the caseous masses are forced from the crypts. If they are full to over- 
flowing, the yellowish spots appear at the mouths of the crypts much 
as they do in the acute form of the disease. 

The tonsils are usually enlarged, and are often greater than they appear 
to be upon superficial examination, as they are covered by the plica 
triangularis and plica supratonsillaris; indeed, some of the largest tonsils 
I have ever removed were thus concealed from view. The plica tonsil- 
laris is not an "adhesion" or inflammatory product, as some authors 
state, but is an embryological structure, as stated in the section on the 
Clinical Anatomy of the Tonsil. When the anterior and median surfaces 
of the tonsil are completely covered by an unusually large plica tonsil- 
laris, the mouths of the crypts cannot be seen without a throat mirror, 



CALCULUS OF THE TONSIL 403 

or putting the patient "on the gag" (Pynehon). By resorting to the 
latter of these expedients, the tonsil is rotated forward so that its median 
surface may be seen by direct inspection. A blunt tonsil hook intro- 
duced into the crypts or into the pocket formed by the union of the 
plica tonsillaris with the tonsil will remove the caseous plugs and develop 
the fetid odor to its full extent. 

Occasionally the mouth of a crypt becomes closed by inflammatory 
adhesions (caseous encyst), and the yellowish color shows through the 
thin membranous covering over the mouth of the crypt. 

A tonsil thus affected is subject to acute exacerbations, generally 
of a mild type, the mucous membrane becoming slightly reddened. 
There is also some soreness upon swallowing. The temperature is but 
little elevated and attracts no attention. The patient sometimes com- 
plains of slight huskiness of the voice, and has fits of coughing which 
result from the local irritation of the tonsil. During these attacks he 
often coughs up the caseous masses. The repeated removal of the plugs 
affords some relief, and their tendency to reform is diminished, though 
a cure by this procedure does not often occur. 

Treatment. — If the symptoms annoy the patient, and recur at fre- 
quent intervals, or if the patient has had rheumatism, enlarged glands 
in the neck, or other evidences of infection in a remote part of the body, 
which may reasonably be assigned to absorption through the tonsils, 
they should be removed in their entirety. 

Slitting the crypt walls, followed by the application of a 20 per cent, 
solution of trichloracetic acid or of strong solution of iodine, has been 
strongly advocated by Kauffmann and Hoi linger. Personally, I do not 
recommend this mode of treatment, as it is, at the best, a makeshift and 
fails to meet the fundamental requirements of the condition. The tonsil 
crypts are diseased, chronically infected, and have a tendency to continue 
in a diseased state. The rational procedure is, therefore, to remove the 
tonsil completely, preferably with its capsule intact. (For a descrip- 
tion of the operation, see Surgery of the Tonsils.) 



CALCULUS OF THE TONSIL 

Small quantities of calcareous or gritty particles are often found in the 
centre of the caseous plugs filling the crypts of the tonsil in chronic 
lacunar tonsillitis. They sometimes become quite large and fill the 
crypts, and are known as calculi of the tonsil. The etiology is not clear 
beyond the fact that they are usually found in tonsils affected by chronic 
inflammation. 

Symptoms. — The symptoms are identical with those of chronic lacunar 
tonsillitis with caseous plugs in the crypts; that is, there are recurrent 
attacks of mild tonsillitis with redness, which is especially marked around 
the affected crypts. 

Treatment. — The treatment consists in the removal of the calculus, or 
the removal of the tonsil, as in chronic lacunar tonsillitis. If the calculus 



404 THE PHARYNX AND FAUCES 

is not easily disengaged from the crypt, an incision of the wall of the 
crypt facilitates its removal. Pain may be obviated by injecting a 4 per 
cent, solution of cocaine into the substance of the tonsil in the region of 
the calculus. 



PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS (QUINSY) 

Phlegmonous tonsillitis is an acute abscess within the substance 
of the tonsil, whereas peritonsillitis is an acute abscess in the peritonsillar 
tissue. The processes are the same, but the location of the purulent 
accumulation is different. Peritonsillar abscess or peritonsillitis (quinsy) 
is much more common than phlegmonous tonsillitis. 

Etiology. — The causation is about the same as that given under acute 
lacunar tonsillitis. Peritonsillitis (quinsy) probably results from an 
infection of the crypts in the supratonsillar fossa, which are large, slit- 
like cavities with irregular outlines, and which are in intimate relation- 
ship with the posterior and outer aspect of the tonsil. The disease is 
common in young adults and rare in children. 

Symptoms. — Phlegmonous tonsillitis is more rare and less severe 
than peritonsillitis. Otherwise the symptoms are much the same. The 
onset of the peritonsillitis is gradual, though there may have been a pre- 
ceding acute lacunar tonsillitis, with its sudden onset and severe symp- 
toms. The temperature rarely exceeds 99° or 100°, whereas in acute 
tonsillitis it often rises to 103°. 

The pain progressively increases with the extension of the purulent 
accumulation until it is almost unbearable. The muscles of mastication 
are encroached upon by the abscess, hence the patient has the greatest 
difficulty in opening the mouth sufficiently wide to permit of an examina- 
tion of the throat. Swallowing becomes difficult and painful. The 
disease is usually limited to one side. The saliva dribbles from the 
mouth and forms one of the characteristic symptoms. Lateral move- 
ment of the head produces pain on account of the infiltration of the 
tissues of the neck in the region of the tonsil. 

Thick viscid secretion forms in the throat, and it is with the greatest 
difficulty that the patient succeeds in removing it. The tongue is heavily 
coated and the breath fetid. Breathing is interfered with on account 
of the swollen mucous and submucous tissue of the pharynx. The 
patient has an anxious expression of countenance. During sleep he 
often has suffocative attacks which awaken him. Laryngeal dyspnea 
from extension of the edema to the laryngeal tissue is fortunately rare. 

Objective Symptoms. — At the onset there is slight redness and swelling 
upon one side. Both tonsils are rarely affected at the same time. If 
both are affected, the second usually begins as the first subsides. If both 
are affected at once, the suffocative symptoms are more severe and 
alarming. As the disease progresses, the redness, tenderness, pain, and 
swelling increase in severity. If the abscess is in the tonsil, it is pushed 
toward the median line or even beyond it. If the abscess is in the peri- 



PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS 405 

tonsillar tissue, the swelling often appears to be in the region of the 
upper portion of the anterior pillar. As a matter of fact, the apparent 
swelling in this region is often the anterior border of the tonsil projected 
against the pillar by the pus behind the tonsil. Incisions in this region 
often fail to reach the pus cavity for this reason; that is, the incision is 
carried directly into the tonsil instead of into the pus cavity outside 
of the tonsil. If the depth of the incision is carried beyond the outer 
border of the tonsil, the pus will be more often found. It should be 
remembered that the anterior third of the tonsil projects forward beneath 
the anterior pillar; hence, in making an incision through the anterior 
pillar to evacuate the pus, it should be made far enough anteriorly to 
escape the anterior border of the tonsil, and should be directed in an out- 
ward and a backward direction, outside of the capsule of the tonsil. If 
these anatomical facts are borne in mind, the anterior incision will nearly 
always evacuate the pus. If a posterior incision is to be made, it should 
be directed outward through the posterior pillar, or in its immediate 
vicinity, as the pus pocket often extends posteriorly to the tonsil. 

The soft palate and uvula, as well as the pharyngeal mucous mem- 
brane, are red and edematous. The region of the tonsil is of a deep, 
dusky red color. The crypts are often filled with a pulp-like debris, 
which was probably the original source of infection. The infection does 
not originate in the peritonsillar tissue, but in the supratonsillar crypts 
of the tonsil. 

Digital examination of the tonsillar region shows more or less distinct 
fluctuation. The focal centre of fluctuation is sometimes located about 
one-quarter of an inch external to the free border of the anterior pillar; 
at the junction of the upper third with the middle third of the tonsil; or 
it may be posterior to the tonsil. 

The duration of the disease embraces from five to fourteen days when 
allowed to run its course, though it may extend over a longer period. 
The termination is marked by the spontaneous or artificial discharge 
of fetid pus. When the discharge is spontaneous, it usually takes place 
through the anterior pillar, though it occasionally occurs through one 
of the crypts. 

Complications and Sequelae. — Complications and sequela? are rare. 
Cases are on record, however, in which the following conditions were 
present: 

(a) Edema of the glottis from the downward extension of the process. 

(6) Strangulation from the spontaneous rupture of the abscess. 

(c) Ulceration thrombophlebitis of one of the large veins of the neck. 

(d) Ulceration of one of the large arteries in the submaxillary region. 

(e) Chronic peritonsillitis with an intermittent flow of pus (Ball). 
(/) Encysted abscess in the tonsil. 

Treatment, — The Onset. — If the case is seen early when infiltration 
and redness of the mucous membrane and the deeper tissues are present, 
but no pus, cold applied in the mouth or externally at the angle of the 
jaw diminishes the pain, and, indeed, may abort the attack. Cold may 
be applied internally by means of iced gargles or by sucking cracked 



406 THE PHARYNX AND FAUCES 

ice. It should be applied externally with a Leiter coil. It should be 
borne in mind that cold applications are indicated in the early stage 
of acute inflammation, whereas hot applications are indicated in the 
later stages. In very acute inflammation, proliferation and local leuko- 
cytosis are active; whereas, in the later stage, cell proliferation and 
local leukocytosis are lessened, though the proliferated cells remain 
permanently; hence, heat is indicated to increase the leukocytosis, as 
the lymphocytes are needed to clear up the inflammatory products and 
the polynuclear leukocytes to destroy the bacteria. 

Pain may be relieved by the inhalation of hot vapors or steam, or by 
the application of hot poultices or a hot Leiter coil to the neck and 
angle of the jaw. Local applications of cocaine may also be used for the 
same purpose. The leukodescent 500 candle-power lamp, when avail- 
able, provides an excellent mode of treatment. The rays of the lamp 

Fig. 264 




The author's dissection back of the capsule of the tonsil to evacuate a peritonsillar abscess. The 
dissection is started as though the tonsil were to be removed, 

should be applied over the neck and angle of the jaw upon the affected 
side. The lamp should first be moved over the neck a few times at a 
distance of six inches, and then more slowly for ten to thirty minutes at 
a distance of eighteen inches. Such treatments will relieve the pain and 
reduce the swelling more readily and certainly than cold applications, 
as they promote the reaction of inflammation and convert the passive 
into an active congestion. 

^ Surgical Treatment— When the process is well established the evacua- 
tion of the pus is imperatively indicated. The point of the incision 
(in quinsy) should be determined by the location of pouching or fluctu- 
ation. It is usually in front of the anterior pillar on a level with the 
junction of the upper and middle thirds of the tonsil, though it may 
be in the posterior pillar or through the tonsil. Some recent writers 
have advocated the posterior pillar as the most favorable site for the 



HYPERTROPHY OF THE TONSIL 407 

incision, whereas most of the earlier authors recommend the anterior 
pillar. As a matter of fact, many of the failures to evacuate the pus 
through the anterior incision are due to a failure to take into account 
the fact that the tonsil often extends forward beneath the anterior pillar. 
The incision as usually made, therefore, penetrates the tonsil instead of 
the tissue outside of it (Fig. 264). 

The Author's Operation. — (a) Inject a 4 per cent, solution of cocaine 
through the anterior pillar into the peritonsillar tissue. 

(b) Seize the anterior portion of the tonsil with forceps and pull it 
medianward and forward to reverse the position of the anterior pillar. 

(c) Make an incision at the junction of the anterior pillar and the 
tonsil, thereby separating the pillar from the tonsil. 

(d) Introduce a blunt dissector through the incision and separate the 
capsule of the tonsil from the superior constrictor muscle (bed of the 
sinus tonsillaris) until the abscess cavity is reached. 

This method of operating can never fail to evacuate the pus. Other 
methods are inaccurate and are often attended with failure. 



HYPERTROPHY OF THE TONSIL. 

This subject is closely akin to chronic lacunar tonsillitis, as in that 
disease the tonsil is nearly always hypertrophied. Likewise the hyper- 
trophic tonsil is nearly always subject to chronic lacunar inflammation. 
Nevertheless, it is practical to consider hypertrophy of the tonsil as a 
separate entity, as there are certain general considerations which justify it. 

Hypertrophy of the tonsil usually begins about the second year of 
life and continues until young adulthood. Instances have been noted 
in which the babe seemed to have been born with enlarged tonsils. It 
is therefore occasionally congenital. While the hypertrophic process 
may continue into young adult life, it generally ceases to develop actively 
after puberty, and often seems to undergo an atrophic change. The 
connective-tissue element develops in excess of the other structures, and 
the tonsil becomes firmer and firmer, and shrinks on account of the con- 
traction of the connective tissue. The difference between a child's 
tonsil and that of an adult is thus explained : In a child the enlargement 
is due to an increase in all the cellular structures composing the tonsil, 
whereas in an adult the connective-tissue cells are increased in excess of 
the other cellular elements (hyperplasia). In a child, the tonsil is soft 
and smooth in outline, whereas in an adult it is often much harder and is 
nodular in outline. In some children the hypertrophied tonsil is so loosely 
attached to the sinus tonsillaris that it can be easily removed in its 
entirety, with its capsule intact, with the tonsillotome. In others it is 
more firmly attached, and the tonsillotome only removes the superficial 
portion. In a few adults the tonsil is loosely attached, though it is ordi- 
narily more firmly attached than in children. The exact size of the tonsil 
is not always shown by the ordinary examination, as only the super- 
ficial portion (median) is visible. The greater portion of the tonsil 



408 THE PHARYNX AND FAUCES 

may be hidden beneath the anterior pillar, the plica tonsillaris, and the 
plica supratonsillaris. Wilson has shown by the examination of a number 
of cadavers that the average height of the tonsil above the margo supra- 
tonsillaris is about J inch. Hence, too much importance should not be 
attached to the apparent size of the tonsil. It should be palpated with 
the index finger through the mouth, and its boundaries defined and its 
movability (degree of attachment) determined. In this way a good 
idea of the degree of enlargement and the ease with which it may be 
removed may be estimated. 

The so-called submerged tonsil' (Pyneh on) is one that has undergone 
fibroid changes and is hidden behind the anterior pillar and the plica 
tonsillaris. Pynchon speaks of the plica tonsillaris as "an hypertrophy 
of the free border of the anterior pillar," whereas it is a normal structure 
appearing in embryonal life, and in some of the lower animals develops 
into the tonsil itself. There is no muscular tissue in the plica tonsillaris, 
and it should be removed with the tonsil. When it is left in place, it may 
form a pocket or pouch where food and other debris collect, and is the 
source of considerable local irritation. 

The hypertrophic and hyperplastic tonsils may have healthy crypts, 
but, as a rule, the reverse is true. The lining epithelium of some of the 
crypts is usually of low vitality, often hornified, and is unable to resist 
the invasion of pathogenic microorganisms. During the transitional 
stage between hypertrophy and hyperplasia of the tonsil, hyperkeratosis 
of the cryptic epithelium may take place (hyperkeratosis of the tonsil). 
The leptothrix (mycosis tonsillaris) is an adventitious complication 
and not a disease per se (G. B. Wood). The hyperkeratosis is a self- 
limited condition, and usually disappears spontaneously in from one to 
three years. 

If an hypertrophied or hyperplastic tonsil gives rise to untoward 
local symptoms, to constitutional disturbances, or to local morbid lesions 
in remote portions of the body, it should be removed in its entirety. 

Treatment* — Palliative treatment directed toward the removal of 
the caseous plugs from the crypts, and from the pocket formed by the 
union of the plica tonsillaris with the tonsil, may be instituted when 
for any reason an operation cannot be performed. The incision of the 
crypt walls and the application of acids or iodine, as advocated by 
Kauffmann, Ball and others, may also be tried, but the best results are 
obtained by the complete removal of the tonsil with its capsule intact. 



HYPERKERATOSIS OF THE TONSIL; MYCOSIS LEPTOTHRICIA 

According to Dr. George B. Wood, hyperkeratosis of the tonsillar 
tissues of the throat is a disease, or, better, a condition, characterized by 
the appearance of numerous white projections not only from the cryptal 
orifices of the tonsils proper, but also from the orifices of the lymph 
follicles on the posterior and lateral pharyngeal walls and on the lateral 
glosso-epiglottidean folds. This condition does not occur on portions of 



HYPERKERATOSIS OF THE TONSIL 409 

the throat where there is no lymphoid tissue. The lymphoid tissue of the 
upper respiratory tract, however, is so ubiquitous that occasionally we 
may see the little white projections on almost any part of the mucosa. In 
the large majority of cases the condition is limited to the faucial and 
lingual tonsils. That it reaches its greatest development on the base of 
the tongue and at a position just behind the lateral glosso-epiglottidean 
folds and the posterior part of the inferior poles of the tonsils is due 
almost entirely to mechanical reasons. The contractions of the muscles 
during swallowing prevent food from coming in intimate contact with 
the surface of these parts, and therefore permit the projections to grow 
undisturbed. Although the horny material is quite resistant to trauma, 
the bacterial accumulations which form the greater mass of the projection 
are easily brushed off, so that the size of the growth is much greater 
where it is protected from mechanical disturbances. 

Fig. 265 




Hyperkeratosis, showing the typical appearance under low power. The horny mass is growing 
from a comparatively small area of the cryptal epithelium, and the plug shows the ordinary fraying 
of its edges : a, cryptal epithelium; b, horny material; c, masses of bacteria; d, follicles. (Wood.) 

The symptoms caused by this condition of the throat are either 
entirely wanting or very slight, and are due for the greater part to the 
local irritation caused by the hard, horny plug. If they project from the 
base of the tongue so as to come in contact with the epiglottis, there is an 
irritating tickling sensation which causes a hacking cough. If they are 
so placed as to be compressed during the act of swallowing, they may 
give rise to a slight pricking pain. 

Occasionally among the rich and various bacterial flora which grow 
in such luxuriance on this horny material, there may lurk a germ pos- 
sessed of more or less pathogenic power, which may set up an accom- 



410 THE PHARYNX AND FAUCES 

panying inflammatory reaction in the tonsil or surrounding structures. 
Hence, the relation which some observers have noticed between acute 
tonsillitis and this disease. 

Dr. Wood also says that to understand correctly the pathology and 
the etiology of lacunar hyperkeratosis, we . must turn our attention for 
a few moments to the anatomy of the normal active tonsil. The tonsil 
consists of four chief elements: the connective tissue, the germinating 
follicles, the interfollicular tissue, and the crypts. 

1. The connective tissue, that is, the trabecula or reticulum, acts as 
a supporting framework to the tonsil substance proper. The trabec- 
ular carry bloodvessels, nerves, and Lymphatics. 

Fig. 266 




Hyperkeratosis, faucial tonsils. This specimen is from a case which had been vigorously treated 
with antiseptics. There are practically no microorganisms. The black staining is due to nitrate 
of silver which has been used in treating the patient: a, keratoid plug; b, intact cryptal epithelium. 
(Wood.) 

2. The germinating follicles (Fig. 265) are the centres wherein the 
larger mother cells of the leukocytic group undergo karyokinesis and 
form young lymphoid cells. 

3. The interfollicular tissue is made up of lymphoid cells in various 
stages of development. The cells making up this interfollicular tissue 
differ in size and shape according to their location. They are greater 
in number around the follicles, and show greater difference in their 
anatomical construction in the immediate neighborhood of the crypts. 

4. The crypt of the tonsil is its peculiar and most characteristic struc- 
ture. It consists of an invagination of the epithelium from the surface 
of the tonsil, which has undergone a very interesting anatomical change. 
In the first place, the subepithelial connective tissue which is present in a 



HYPERKERATOSIS OF THE TONSIL 



411 



marked degree beneath the surface epithelium disappears as soon as the 
epithelium starts to form the crypts. This permits the epithelial cells 
to come in direct contact with the lymphatic structures of the tonsil, 
and very frequently it is impossible to distinguish a dividing line between 
the epithelium of the crypt and the interfollicular tissue. The epithelium 
of the crypt, unlike its progenitor, which covers the surface of the tonsil, 
does not form a compact unbroken barrier or protection. For the greater 
part of its extent it presents an intact line only one or two or possibly three 
cells in thickness. Toward the parenchyma the epithelial cells show a 
peculiar condition. They are separated from each other by interposed 
cells varying in type from slightly changed epithelial cells to well-formed 
lymphocytes. The epithelial cells may also extend from the crypt 
into the tonsillar substance, suggesting the ramifications of a malignant 



Fig. 267 




Hyperkeratosis. 



Cross-section of a crypt filled with keratoid material and bacteria: 
epithelium; b, hornified cells; c, lymphoid tissue. (Wood.) 



epithelioma. The smaller terminal invaginations of the cryptal epi- 
thelium are usually solid sprouts, frequently with central keratosed 
cores. The lumen of the crypt is formed by the subsequent exfoliation 
of the keratosed cells. 

"Turning now to hyperkeratosis, we find the epithelium of the crypts 
showing characteristic changes. In hyperkeratosis the epithelium loses its 
rarefied condition and becomes ordinary pavement squamous epithelium 
similar to that covering the surfaces of the tonsil, except that generally 
it does not show the connective-tissue papillae. The crypt of the tonsil is 
markedly dilated and filled with a horny mass (Fig. 267), which merges 
at various pointsinto the epithelium, though in sections stained with eosin 
and thionin there seems to be a more or less distinct line where the epi- 
thelial cells become keratosed. The living cell has a nucleus which stains 



412 



THE PHARYNX AND FAUCES 



with thionin, and its protoplasm is of a purplish color, due to the mixed 
staining with eosin and thionin. The keratosed material stains only 
with eosin, and is, therefore, of a bright pink color. Occasionally in the 
keratoid mass a very faintly stained nucleus is found, indicating that the 
material of which the mass consists has been originally derived from 
epithelial cells. 

"According to the mechanical circumstances by which the tonsil 
is surrounded, the horny mass becomes sooner or later broken up into 
layers, between which multiply and grow organisms of all varieties. This 
fraying of the cryptal plug may take place within the crypt itself, so that 
the resulting fissures permit the bacteria at times to penetrate almost 



Fig. 268 

a 




aHE 




Hyperkeratosis. Cross-section of the terminal portion of a crypt sh owing the concentric arrange- 
ment of the layers of horny material and the epithelium, which is still somewhat disintegrated: 
a, epithelium; b, horny material in crypts; c, lymphoid tissue. (Wood.) 



but not quite to the living epithelium. Mytotic figures may be seen 
in the epithelium at different places, but especially along the border 
toward the parenchyma of the tonsil. The epithelium is, therefore, in a 
state of active growth. This eccentric growth, however, which results 
in the formation of the keratoid plug, is not equally distributed to all 
parts of the epithelial lining of the tonsillar crypts. Take, for instance, 
a single individual crypt : a portion of the epithelium may still persist in 
its normal condition of partial disintegration without a discernible border 
line between it and the tonsil parenchyma ; in another part the epithelium 
may exist simply as a barrier of cells with a very thin layer of subepi- 
thelial connective tissue, and again in the same crypt we may see the 
hyperkeratosis in its most beautiful and characteristic appearance. 



HYPERKERATOSIS OF THE TONSIL 413 

"This change in the epithelium of the crypts is the characteristic patho- 
logical feature of hyperkeratosis. Besides this there are generally other 
changes in the tonsil. The connective tissue extends from the surface 
epithelium for some distance down along the crypt. The follicles are 
small and much less numerous, and the surrounding zone of lymphocytes 
has become comparatively insignificant. The mitotic figures in the 
follicles, though present, are less numerous, and the whole aspect of 
the organ is one of suppressed activity. We sometimes find, however, 
signs of local irritation in the immediate neighborhood of the crypts, as 
evidenced by the outwandering of polymorphonuclear leukocytes from 
the capillaries and their penetration between the cells of the cryptal 
epithelium. This irritation is easy to understand when we consider 
that the crypts contain a large number of saprophytes and probably 
also pathogenic microorganisms growing actively and receiving their 
nutriment from the accumulated keratosed cells. 

"The toxins elaborated by these organisms must be absorbed to a 
greater or less extent by the tonsillar tissue. It is probably due to the 
fact that the cryptal epithelium has become an impact protective barrier 
that a more noticeable reaction is not a common result." 

Hyperkeratosis is a condition peculiar to young adults, and is self- 
limited, from two to three years being required for it to run its course. 
Treatment is unnecessary, though if the horny masses cause irritation 
they may be removed by cauterization. The electrocautery should be 
used to destroy them, and the surrounding tissues should be penetrated 
until only healthy tissue remains. From three to four masses may be 
thus treated at each sitting at intervals of one week. 



CHAPTEE XXIII 

SURGERY OF THE TONSILS 

It is being more and more recognized that the complete enucleation 
of the tonsil within its capsule is the most satisfactory method of dealing 
with diseased tonsils. It is true that in a certain number of cases the 
distressing symptoms yield to less radical measures, such as the applica- 
tion of the cautery to the crypts, the incision of the crypts, the removal of 
the retained debris from the crypts, and the partial removal of the tonsil. 
I believe that if these cases were observed for a period of five or more years 
it would be found that the tonsil is still the seat of diseased processes not 
unlike those present before the operations above named. In addition 
to the diseased conditions it would also be found that in some instances 
the tonsillar tissue had grown again, oftentimes in greater bulk than 
before the operation. 

If, on the other hand, the tonsil is removed in its entirety, with its 
investing fibrous capsule, the diseased processes in the tonsillar fossa 
and the tonsillar tissue will never recur. F. E. Hopkins, in a review of 
the literature since 1856, found several recorded cases of recurrence, 
chiefly before the year 1870, though instances of recent date were also 
cited. His conclusion coincides with that of Sir Morrell Mackenzie, 
Sir Felix Semon, and the author, that recurrence is nearly always due 
to incomplete removal of the tonsil. D. Braden Kyle expresses the 
opinion that some cases of apparent recurrence after excision of the 
tonsil are, in reality, the regrowth of an adenoma, the tonsil having 
taken on that type of benign neoplastic development. N. L. Wilson says 
that the complete removal of the tonsil may be followed by an inflam- 
matory process in the tonsillar fossa, but that such processes will not 
often be found after a period of two years subsequent to the operation. 
Tuberculous and specific taints no doubt cause some of the recurrences 
after tonsillotomy. 

It seems to me, therefore, after considering all the data obtainable, 
including my own experience, that many of the conditions heretofore 
regarded as necessitating only cauterization, incision, partial removal, 
etc., should be operated on by the complete method, whereby the entire 
tonsil with its investing fibrous capsule is removed. 

Indications for Operation. — In the following paragraphs it should be 
remembered that the indications stated have special reference to the 
complete operation technically known as tonsillectomy: 

According to George B. Wood, it is impossible except in certain acute, 
well-marked pathologic lesions of the tonsil to determine clinically 
the exact condition of the tonsil parenchyma. Tonsils which appear 
(414) 



THE SURGERY OF THE TONSILS 415 

to be diseased were found microscopically to consist of normal tissue, 
while on the other hand innocent appearing tonsils presented various 
suppurative or tuberculous lesions in the deeper structures. 

Much has been written, and but little determined, concerning the 
internal secretion of the tonsil. Of the more recent writers, Dr. J. G. 
Wilson says: "The tonsil does not develop like a lymphatic gland from 
a plexus of preexisting lymph vessels in the mesothelium. It develops 
as an ingrowth of endothelium from the second branchial pouch, and 
in its origin comes into line with the thymus and the thyroid, for I need not 
remind you that the thymus originates from the third branchial pouch, 
the thyroid from the fourth and the parathyroid from the third and fourth, 
all by imbudding of the endothelial lining of the primitive pharynx." 

Dr. George B. Wood says there has been a great deal of guesswork 
as to the function of the tonsil, but that the only physiologic property 
they have been proved to possess is the production of lymphocytes in 
the germ centres or follicles, and that therefore the removal of the 
tonsils after the first two or three years of life removes only a very 
small fraction of the normal supply of lymphocytes. He has never 
seen a case in which the absence of the tonsillar tissue was harmful to 
the individual. He advocates the complete enucleation of the tonsil. 

(a) Nasal catarrh and (b) diseases of the ear are sometimes true indi- 
cations for tonsillectomy. Pychon says: " In a goodly number of those 
cases applying for treatment for nasal catarrh, or for ear disease, in which 
a plainly apparent hypertrophy of the faucial tonsils does not exist, it will 
be found upon close inspection that there is present a certain degree of 
faucial fulness which is markedly increased by causing the patient to gag. 
Among the embellishments of this every-day picture an abnormal faucial 
redness is observed, gradually increasing in depth of color from the normal 
pale pink of the lowest point of the pharynx disclosed by the use of the 
tongue depressor. There will also be observed a tendency for frothy 
saliva to adhere to the parts." The relationship between nasal catarrh 
and tonsillar disease is not perfectly clear, while that between the tonsil 
and the ear is more apparent, as the palatopharyngeus muscle extends 
to the pharyngeal orifice of the Eustachian tube, and inflammation 
of the tonsils and pillars might readily extend along the pharyngo- 
palatine fold to the mucosa of the tube, and thence to the middle ear. 
Repeated attacks of angina in this region may result in degeneration of 
the palatopharyngeal muscle fibers and thus impair the muscular mech- 
anism that controls the patency of the tube. Again, infectious material in 
inflammation of the tonsil may gain entrance to the tube and middle ear, 
either during coughing or vomiting, or in intense inflammation by the 
destruction of the cilise of the epithelium of the tube. Ordinarily, the 
cilise with their wave-like motion carry the secretions from the middle 
ear to the epipharynx. When they are destroyed, or their action is 
inhibited by violent inflammation, the entrance of foreign matter, as bac- 
teria, etc., into the middle ear is comparatively easy. Hence, in certain 
diseases of the ear which have their origin in tonsillar inflammations, the 
removal of the tonsil is indicated. 



416 THE PHARYNX AND FAUCES 

(c) Recurrent attacks of tonsillitis, which are independent of aural 
or pharyngeal complications, usually justify the enucleation of the 
tonsils. The operation should not, of course, be done during one of 
the acute manifestations, as to do so might give rise to severe infection 
of the wound and deeper structures. 

(d) By referring to Fig. 262 it will be seen that the tonsils drain into 
the deep glands of the neck. When these glands are enlarged and tender, 
the tonsils are usually the source of the infection; and if there is a history 
of repeated glandular involvement, the tonsils should be excised. 
According to George B. Wood there are afferent lymph channels to 
the tonsil. 

(e) When the crypts of the tonsils are examined and they are found 
more or less filled with debris and bacteria, tonsillectomy should be 
considered. If the debris is removed with a tonsil hook or with a tonsil 
syringe, the inflammation is temporarily relieved, but in most instances 
it returns. If after repeated trials the inflammation recurs, tonsil- 
lectomy is indicated. 

(/) Laryngitis with attacks of hoarseness is often due to tonsillar dis- 
ease, hence the tonsils should always be examined ; and if the crypts are 
diseased or the tonsils are hypertrophied, the tonsils should be removed. 

(g) Hypertrophy of the tonsils is an evidence of a disease process, for 
in a perfectly normal throat they are of small size. There is a divergence 
of opinion upon this point; some writers hold that the tonsil is an organ 
of the body, while others believe it to be a pathological entity. Bacterial 
infection, when long continued, causes either hypertrophy or hyperplasia. 
When thus changed, its function as a lymphatic gland is impaired or 
lost, and the physical economy is best served by its complete ablation. 

(h) Chronic follicular tonsillitis is an indication for tonsillectomy, as 
there is little likelihood of curing it by simpler methods. Even if the 
crypts are closed by the use of the cautery, the low vitality of the tissue 
predisposes to infection and inflammation. 

(i) Follicular pharyngitis is, according to George Troup Maxwell, 
often caused by a chronic suppurative follicular tonsillitis. He claims 
that after the tonsils are removed, the follicular pharyngitis disappears. 

(j) Tuberculous infection often begins in the tonsils, and when such 
a process is demonstrated or strongly suspected, the tonsils should be 
enucleated. 

(k) Recurrent acute articular rheumatism following acute tonsillitis 
is an indication for tonsillectomy. 



OPERATIONS ON THE TONSILS 

There are so many methods of operating upon the tonsils for the cure 
or relief of the morbid conditions affecting them and the neighboring 
structures and organs, that it is impracticable to attempt to describe 
all of them. I shall, therefore, select those methods which appeal to 
me as the most rational from a clinical and surgical standpoint, and 



OPERATIONS ON THE TONSILS 417 

which have, after long trial, given the best results. Some of the proce- 
dures to be described are not recommended as the best, but under some 
circumstances they must be resorted to as preliminary or tentative 
measures. Hemophilia, reluctance or refusal of the patient to sub- 
mit to what seems to be the best method, will occasionally lead the 
surgeon to elect the incomplete method of operating. Hence, both com- 
plete and incomplete operative procedures will be described and their 
comparative merits stated as fairly as possible. 

Complete Operations.— By the term "complete operations/' I mean 
those surgical procedures whereby the faucial tonsil is removed in its 
entirety, either en masse or piecemeal. Clinical observations have clearly 
shown that any procedure short of this is often followed by little or no 
permanent improvement in the conditions for which it was done. Numer- 
ous cases are on record, and doubtless many more are unrecorded, in 
which there was a continuation of the pathological processes, and recur- 
rence of the tonsillar tissue after incomplete operations. 

As has been stated in a preceding paragraph, even after the complete 
removal of the tonsil, the sinus tonsillaris is sometimes the seat of an 
inflammation, but it rarely persists for more than two years. I can say 
from a personal experience covering about 5000 cases, in which the 
tonsils were removed in their entirety with the investing capsule intact, 
that such subsequent inflammations have been exceedingly rare, while 
recurrence of the tonsillar tissue has never taken place. 

On the other hand, I can refer to a large number of cases in which I 
performed an incomplete operation, or what is known as "clipping the 
tonsils," with a Mathieu's tonsillotome or other instrument, in which 
the subsequent tonsillar inflammation occurred comparatively fre- 
quently. 

It seems, therefore, that the time has come when a text-book should 
clearly recommend the complete operations upon the tonsils as the 
ones that should be used if it is at all expedient to do so, and that the 
incomplete operations should be resorted to only when the peculiar 
conditions of the patient contra-indicate any of the complete methods, 
or when other circumstances prevent their adoption. 

The Author's Complete Operation with Right-angle Knife and Ecraseur. 
— While every detail in the following technique is not original with me 
the operation as a whole has been my own creation, especially with refer- 
ence to the removal of the entire tonsil with its capsule intact. In most 
cases the diseased tonsil is composed of three lobes, or masses, each with 
an investing capsule, the three lobes being held together by a fibrous 
envelope, or secondary enveloping capsule. For all practical purposes, 
the tonsil may be regarded as one mass with an investing capsule, and 
as such it may be removed in its entirety. 

(a) Anesthesia may be either local or general. Personally, I prefer 
local anesthesia, except in those cases in which, for various reasons, the 
patient cannot be operated upon in the conscious state. This is a matter 
that must be decided by each surgeon, as the personal element enters so 
largely into its consideration. 
27 



418 



THE PHARYNX AND FAUCES 



Local anesthesia may be induced by swabbing the tonsils and the 
faucial arches at intervals of five minutes with an aqueous solution con- 
taining 10 per cent, of cocaine and 5 per cent, of carbolic acid. Both 
ingredients produce blanching and anesthesia. From five to ten appli- 
cations are usually required to produce complete anesthesia. In some 
cases a single application of a 20 per cent, solution of cocaine should be 
applied. The frequent use of a 20 per cent, solution is quite likely to 
produce toxic results. 

Fig. 269 




Street's tonsil hypodermic syringe. 

Thorough anesthesia may be produced by using the weakest prepara- 
tion of Schleich's solution in much larger quantity. I now use this 
solution, injecting ^ dram into the peritonsillar tissue, and waiting five 
minutes for its anesthetic effect. Adrenalin may be added to the 
solution to reduce the hemorrhage. 



Fig. 270 




The author's tonsil forceps. 

The position of the patient is a matter of some importance. Under 
local anesthesia the upright position in the operating chair should be 
used. Under general anesthesia the patient is placed upon the operating 
table, with his head either over the end of the table in the Rose position, 
or upon his side (Fig. 236), according to the preference of the surgeon. 
A mouth gag (Fig. 237) should be used if a general anesthetic is given. 

In the further description of the technique, I will assume that the 
patient is conscious and in the upright position. 

(b) Seize the tonsil with the vulsellum forceps (Fig. 270) ; the tip of 
one prong should be placed in the supratonsillar fossa and the other at 
the base of the tonsil. When they are thus placed, they should be 
pushed deep into the tissues, closed, and locked. In this way they 
engage the fibrous capsule or deep surface of the tonsil, and will not tear 
loose except in young children when traction is made. 

When the blades are closed the bulk of the tonsil lies between the 
shanks of the instrument, as shown in Fig. 271. This has a distinct 
advantage over a superficial grasp of the tonsil, as it enables the surgeon 



OPERATIONS ON THE TONSILS 



419 



to dissect it with greater ease. It also enables the operator to bring the 
posterior pillar into easy reach of the tonsil knife. 

(c) Dissect die anterior pillar from the tonsil and carry the incision 
above the margosupratonsillaris, or the supratonsillar space, to the 
posterior pillar (Fig. 271). The aim should be to dissect around the 
upper half of the tonsil, removing the mucous membrane forming the 
roof or dome of the supratonsillar fossa. These details are important 
if it is the intention to remove the tonsil with its fibrous capsule intact. 
The incision thus assumes the form of an inverted U. The instrument 
used is a right-angle knife. It should be hooked into the mucosa at the 
junction of the anterior pillar with the plica triangularis (Fig. 271). 
It is then pulled toward the median line of the throat, thus severing the 
pillar from the plica triangularis and the tonsil. Reintroduce the hook 
blade into the incision thus made and engage it as before, and pull 
toward the median line. Two or three such cuts are required to bring 
the incision above the supratonsillar fossa. While the foregoing incision 
is being made, the tonsil is in the grasp of the vulsellum forceps, and it is 
pulled forcibly toward the median line. This stretches the pillar and 
greatly facilitates its separation from the tonsil with the hook knife. 

Fig. 271 




The primary incision being made with the right-angle crypt knife. The knife is introduced 
through the mucous membrane at the junction of the anterior pillar, and the plica triangularis upon 
being pulled forward makes the incision b; the knife is again introduced through the incision as 
shown (a) in the illustration. The incision is thus completed by three or four cuts with the knife. 



The posterior pillar should next be separated in much the same man- 
ner. This pillar is not as accessible as the anterior one, but it can be 
brought into view by rotating the handle of the vulsellum forceps, thereby 
turning the tonsil upon its lateral axis in such a way as to bring the 
posterior pillar forward and upward, where it is readily accessible to 
the hook knife (Fig. 272). 

The two incisions should be united above the margosupratonsillaris. 
Observe carefully the margin of mucous membrane forming the roof of 
the supratonsillar space and make the incision just above it. 



420 



THE PHARYNX AND FAUCES 



The combined incisions are thus converted into an inverted U-shaped 
incision. 

(d) Again seize the tonsil with the vulsellum forceps, with the upper 
prong tip introduced into the supratonsillar portion of the incision, and 

Fig. 272 




Showing the dissection of the posterior pillar from the tonsil with the right-angle knife. The 
tonsil is turned forward upon its lateral axis with the author's vulsellum forceps to bring the pillar 
upon the upper surface, where it is accessible to the knife. 

the lower prong tip at the base of the tonsil. The tonsil is thus well 

within the grasp of the forceps and is ready for dissection with the 

hook knife. 

(e) Pull the tonsil toward the median line, thereby putting the fibers 

attaching it to the superior constrictor muscle upon a tension. With 

the hook knife sever the fibrous 
fig- 273 bands'- (Fig. 273), following the 

external contour of the tonsil to 
its inferior portion. It may be 
necessary to dry the wound 
during the operation, even though 
cocaine-adrenalin solution has 
been injected. If anesthesia 
has been induced by brushing 
the tonsil with cocaine without 
adrenalin the hemorrhage may 
be considerable. 

(/) At this stage of the opera- 
tion the use of the knife may 
be abandoned and the author's 
ecraseur tonsillotome substituted 
(Fig. 274) to complete the opera- 
tion. This shortens the time 
of operation, though it may be 
completed with the knife. 
(g) Pass the forceps through the ring blade of the ecraseur and seize 

the tonsil, then pass the ecraseur over the tonsil as shown in Fig. 276. 




The tonsil in the process of dissection with 
Kyle's crypt knife. During the dissection the 
tonsil is forcibly drawn toward the median line 
of the fauces with the author's vulsellum tonsil 
forceps. 



OPERATIONS ON THE TONSILS 



421 



Close the instrument and thus complete the operation. The dull ring 
blade of the ecraseur readily passes behind the tough fibrous capsule 
of the tonsil and makes a clean dissection of its lower portion. 



Fig. 274 




The author's tonsil ecraseur, a substitute for the snare. 



Fig. 275 




a, the tonsil in the grasp of the author's tonsil forceps; b, the upper half of the tonsil a has 
been enucleated by dissection with its capsule intact. 



The wire snare, on the contrary, tends to cut through the capsule and 
leave the lower portion of the tonsil in situ. 



422 



THE PHARYNX AND FAUCES 



If hemorrhage follows the operation, it may be controlled by swab- 
bing the sinus tonsillaris with a solution of permanganate of potash, f to 
1 grain to the ounce of water. Peroxide of hydrogen may also be 



Fig. 276 




The final step of the tonsillectomy as performed with the author's tonsil ecraseur, a substitute 

for the tonsil snare. 



Fig. 277 




Pynchon's tonsil hemostat. 



Fig. 27 




Boetcher's tonsil hemostat. 



used for the same purpose. Stronger remedies are rarely required. 
Continuous gargling with iced water often controls it. Tonsil clamp 
forceps (Figs. 277 and 278) need rarely be used. 



OPERATIONS ON THE TONSILS 



423 



Fig. 279 



The advantage of the author's tonsil ecraseur over the tonsil snare 
is, that it is always ready for use, whereas the wire of the snare needs 
adjustment each time it is used. When two tonsils are to be removed, 
the wire for the snare must either be straightened or another one inserted 
before the second tonsil can be removed. This is not true of the ecra- 
seur, as it is always ready for use, like an ordinary tonsillotomy The 
edge of the fenestrated blade is round, thus conforming to the cutting 
surface of a wire. (Sharp blades are also furnished with the instrument.) 
If, as claimed, little hemorrhage follows dull dissection, the ecraseur meets 
this requirement. The same is true of the cold-wire snare. After many 
dissections with the ecraseur, I have 
rarely known it to fail to complete 
the dissection of the tonsil with its 
capsule intact. 

This method of removing the ton- 
sil with its capsule intact, while not 
based upon as good surgical tech- 
nique as the author's method with 
a scalpel, is easier for the average 
operator to perform than the dis- 
section with the scalpel. I prefer 
dissection by means of the scalpel 
because I can do it in much less 
time, with less hemorrhage, and less 
discomfort to the patient. I also 
prefer this method, because I believe 
the wound after a clean dissec- 
tion with a sharp knife heals more 
kindly and quickly than the wound 
after dull dissection. 

Tonsillectomy with a Scalpel. — The 
Author's Operation. — After having 
tried almost every known method 
of removing tonsils in the adult, the 

simplest of all instruments was found to be the best adapted for the 
purpose. A small scalpel (Fig. 280) is the instrument used in all 
cases. The only other instrument required is the vulsellum forceps 
(Fig. 270). A tongue depressor is not used, as the forceps crosses the 
tongue and keeps it out of the way. 

Technique. — (a) Induce anesthesia by the injection of the cocaine- 
adrenalin or the infiltration solution in the peritonsillar tissue. If the 
cocaine-adrenalin solution is used, only 8 or 10 minims should be 
injected. If Schleich's No. 3 solution is used, 1 to 2 drams should be 
injected, and a period of from one to five minutes allowed to inter- 
vene between the injections and the operation (Fig. 279). 

(b) Seize the tonsil with vulsellum forceps, one blade in the supra- 
tonsillar fossa, the other at its base, as in the preceding method. Pull 
the tonsil medianward and forward to dislodge the anterior shoulder 




Schema showing the points of injection of 
adrenalin and cocaine solution preliminary to 
the removal of the tonsil with its capsule in- 
tact. About 2 minims of the solution is in- 
jected at each point. If a ■§■ gr. Schleich's 
solution is used (infiltration anesthesia) \ to 
2 drams may be injected at a and b. 



424 



THE PHARYNX AND FAUCES 



from beneath the anterior pillar. This pulls the posterior margin of 
the pillar forward and facilitates the introduction of the scalpel between 
it and the tonsil. 

(c) Introduce the blade of the scalpel to a depth of about one-half 
inch between the anterior pillar and the tonsil at the junction of the 
pillar and plica tonsillaris (Fig. 281). Sweep the blade upward to the 
margosupratonsillaris, and thence over the margosupratonsillaris to 
the posterior pillar (Fig. 282). The knife should be very sharp for this 
purpose. This completely severs the tonsil from the anterior pillar and 

Fig. 280 



The author's tonsil knife. 

exposes the outer aspect of it to further dissection. By including the 
margosupratonsillaris in the incision, the upper portion of the tonsil con- 
cealed in the supratonsillar fossa is freed from its attachments. If this 
step of the operation is not observed, the dissection is more difficult. 

Casselberry called attention to the advantage of dividing the mucous 
membrane along the margosupratonsillaris. He claimed that this 

Fig. 281 




The rirst incision in the removal of the tonsil with its capsule intact. The tonsil is drawn forward 
and medianward from the sinus tonsillaris. The incision is extended upward over the margo- 
supratonsillaris to the posterior pillar. 



procedure rendered the liberation of the velar lobe, or supratonsillar 
portion of the tonsil, much easier and more certain. Without knowing 
of Casselberry's recommendation, I arrived at the same conclusion, 
though my technique is quite different from his. 



OPERATIONS ON THE TONSILS 



425 



By my method, the mucous membrane is divided at the junction of 
the plica tonsillaris and the anterior pillar, and the incision is then 
extended along the margosupratonsillaris to the posterior pillar, as 



Fig. 282 




Anatomical landmarks of the fauces: a, b, the incision liberating the pillars in the removal of 
the tonsil; c, plica tonsillaris; d, anterior pillar; e, supratonsillar slit-like crypts, or hilum of the 
tonsil; f, supratonsillar fossa; g, margosupratonsillaris. 

shown in Fig. 282. If this preliminary incision is thus made, the subse- 
quent steps of the operation will be more easily accomplished ; indeed, the 
dissection of the tonsil is nearly consummated by this procedure alone. 

Fig. 283 




The tonsil being separated from the bed of the sinus tonsillaris, to which it is loosely attached, 
the capsule is followed closely with the author's scalpel, care being exercised to avoid injuring the 
superior constrictor muscle, which forms the bed of the sinus tonsillaris. 

(d) Continue to pull upon the tonsil with the forceps. Then intro- 
duce the knife through the upper part of the incision, follow closely the 
capsule of the tonsil, and sever it from its attachment to the superior 
constrictor muscle, as shown in Fig. 283. The branches of the tonsillar 
artery are severed in this step of the operation. They are small and do 



426 



THE PHARYNX AND FAUCES 



not often give rise to hemorrhage. If, however, some of the fibers of the 
superior constrictor muscle are accidentally removed the main stem of the 
artery is severed and the hemorrhage may be severe. If the hemorrhage 
is severe, the bleeding points should be seized and twisted with artery 
forceps. The edge of the blade should be slightly turned to the tonsil, 
as this will avoid injuring the superior constrictor muscle of the pharynx. 

Fig. 284 




The tonsil is drawn toward the median line of the throat to expose the posterior pillar to the knife. 
The pillar is incised to the bottom of the tonsil at its junction "nith the tonsil. 

(e) Disengage the vulsellum forceps from the tonsil and place the tip 
of one prong in the anterior aspect of the wound, the other over the 
inner aspect of the tonsil, and close them upon the tonsil (Fig. 284). 
Tract the anterior border of the tonsil toward the median line of 
the throat, using the posterior pillar as a hinge. 

(/) Then, having rendered the 
FlG - 285 posterior pillar accessible, shave it 

free from the posterior border of 
the tonsil with the scalpel (Fig. 
284) . Great care should be taken 
to avoid injuring the muscular 
tissue of either the anterior or pos- 
terior pillars during the dissection. 
If the muscles are not injured, 
there is little chance of hemor- 
rhage from these regions, as the 
artery is within the muscular sub- 
stance of the pillars. 

(g) The tonsil is now only 
attached at its inferior portion. 
While still pulling the tonsil 
toward the median line of the throat, complete the dissection by 
cutting downward and medianward. The tonsil is thus removed 
with its capsule intact. The first incision separates the anterior pillar 




The Beck-West method of beginning the enu- 
cleation of the tonsil, i. e., by separating the 
posterior pillar. 



OPERATIONS ON THE TONSILS 427 

and the plica supratonsillaris from the anterior and superior surfaces 
of the tonsil. The second separates the outer surface of the tonsil from 
the superior constrictor muscle of the pharynx. The third separates the 
posterior pillar from the corresponding border of the tonsil. The fourth 
incision completes the dissection by freeing the inferior attachment of 
the tonsil from the pharyngeal wall. 

Since adopting this method of operating, I have seen no alarming 
hemorrhages except in a few instances, in which some fibers of the 
superior constrictor muscle of the pharynx were injured. The hemor- 
rhage was primary, and was easily controlled by a solution of perman- 
ganate of potash (| grain to the ounce of water) or with a hemostat. 

The Complete Removal of the Tonsil with a Tonsillotome and Punch 
Forceps. — This method of operating is the simplest way to remove the 
entire tonsil, and is especially recommended for children with large 
protruding nostrils. It is also recommended to general practitioners and 
inexperienced throat surgeons in both children and adults on account 
of its simplicity and thoroughness. I have used it in hundreds of cases 
with complete satisfaction. 

Fig. 286 



Tonsillotome. 

Technique. — (a) Induce cocaine anesthesia. 

(b) Remove as much of the tonsil with the tonsillotome (Fig. 286) as 
possible. (See Tonsillotomy.) 

(c) Remove the remaining substance of the tonsil with the Ruault, 
Rhodes, or Farlow punch forceps. The forceps should have a heavy 
female blade, with a wide flange, to push the pillars away from the male 
or punch blade (Fig. 287). The closed forceps should be introduced 
between the pillars with the cutting surfaces at right angles to the 
pillars, as in this position they may be opened and closed without 
cutting the pillars. If introduced with the cutting surface of the 
blades parallel with the pillars, the pillars may be injured or cut away. 
When properly placed the forceps should be forced into the sinus ton- 
sillaris and opened and closed until the remainder of the tonsil is com- 
pletely removed. I use the Ruault forceps and exert from five to twenty 
pounds' pressure upon the shank of the instrument with the left hand 
while it is in action. I have never injured the superior constrictor 
muscle with it, nor have I failed to remove all the remaining tonsillar 
tissue with it. 

(d) When the punch forceps are removed the index finger should 
be introduced into the wound to search for fragments of the tonsil. 



428 



THE PHARYNX AND FAUCES 



These fragments feel firm to the touch, and in sharp contrast to the 
smooth and soft bed of the sinus. If fragments of the tonsil still remain 
in situ, introduce the punch forceps and remove them. 



Fig. 287 




The removal of the tonsil with the Ruault tonsil punch forceps after the preliminary 
separation of the pillars. 

(e) Having completed the operation, mop the sinus tonsillaris free of 
blood and search for bleeding points. If found, seize them with an artery 
forceps and twist them. 

Fig. 288 




Robertson's tonsil scissors. The scissors are made in pairs. 



Robertson's Operation. — Robertson's method of removing the tonsil is 
as follows : (a) A general or local anesthetic may be used. 

(b) The anterior and posterior pillars are first separated from the tonsil 
with a curved double-edged knife, or, if the pillar is adherent, with his 
pillar scissors. 

(c) The tonsil is then grasped with forceps and pulled forward and 



OPERATIONS ON THE TONSILS 



429 



inward, the scissors pushing the pillars back out of the way. The 
scissors are then closed and the tonsil removed by a series of cuts 
(Figs. 288 and 289). The tonsil upon the opposite side shows the 
position of the tonsil before it was pulled from its sinus. 



Fig. 289 




The removal of the tonsil with Robertson's scissors. 



This operation may also be performed under local anesthesia, as in 
the author's method. The tonsil may. also be removed in its entirety 
with its capsule intact by this method, though Robertson did not advo- 
cate this until recently. The tonsil scissors are made in pairs to adapt 
them to either side. This 

method of removing the ton- FlG - 29 ° 

sils is thorough and commend- 
able. The prime question in 
reference to any operation on 
the tonsils is that of its com- 
pleteness. 

Pynchon's Cautery Dissection 
Operation. — According to Pyn- 
chon, this method of removing 
the tonsil in its entirety pos- 
sesses the advantages of (a) but 
slight or no primary hemor- 
rhage, and (b) the sealing of 
the wound by the eschar, thus 
preventing severe infection of 
the wound. Dr. Pynchon was 
the first to systematically remove the tonsil in its entirety, he having 
done this for twenty-five years. He did not, however, attempt to remove 
it with its capsule intact, as I have done for fifteen years. 

Technique. — (a) Induce local anesthesia by repeated swabbings, 
first with a 10 per cent, solution of cocaine, and then with a 20 per cent. 




Pynchon's cautery dissection. 



430 THE PHARYNX AND FAUCES 

solution. To each solution of cocaine should be added one-half as muc 
carbolic acid as cocaine. If preferred, the anesthesia may be induced 
by injecting cocaine and adrenalin or the infiltration solution. 

(b) Seize the tonsil with mouse-toothed forceps at about its central 
portion and pull it inward and backward, thus putting the plica tonsil- 
laris and the anterior pillar upon a tension. This renders the anterior 
border of the tonsil easily discernible. 

(c) With a nearly straight cautery electrode at a cherry-red heat, 
puncture the membrane at the junction of the anterior pillar and the 
plica tonsillaris about one-third the distance from the top of the tonsil, 
and dissect downward to the tongue. Then dissect upward over the 
margosupratonsillaris and a little way down the posterior junction of 
the tonsil and pillar (Fig. 290). In other words, make the incision 
shown in Fig. 282. 

(d) With a nearly right-angle electrode (Fig. 290), complete the dis- 
section of the posterior pillar from the tonsil. 

(e) Pull the top of the tonsil inward and downward, and dissect it, 
with the electrode, from its attachment to the superior constrictor muscle, 
thus freeing it from the sinus tonsillaris. 

(/) The remaining pedicle, at the base of the tonsil, is severed by 
stretching it over the heated electrode. 

(g) Only one tonsil is removed at a sitting, the remaining tonsil being 
removed in about two weeks, or after the first wound has healed. 

(h) Applications of a 20 to 30 per cent, aqueous solution of the nitrate 
of silver may be made from time to time during the operation, to check 
oozing hemorrhage. 

(i) The after-treatment should consist in the use of alkaline and 
aromatic gargles and the daily application of the following mixture: 

]$— Tr. iron, 

Glycerin aa 5j 

The above mixture should be rubbed into the wound with a cotton- 
wound applicator, to prevent infection and exuberant granulations. The 
wound should heal with a smooth surface and without the formation 
of cicatricial bands. If the muscular tissue of the pillars is injured, 
contracture and disagreeable deformity of the fauces may result. 

The Sluder Guillotine Operation.— Sluder's method of removing 
tonsils is unique in its simplicity, and because it reverts to the use of 
an old, and, in America, almost obsolete instrument, namely, the 
guillotine. The guillotine and tonsillotome have in America been sup- 
planted by various dissecting knives and scissors, some blunt-tipped, 
curved, ^ angular, etc., in an endeavor to adapt them to the peculiar 
anatomical requirements (real and imaginary, mostly the latter) fcr the 
complete enucleation of the tonsil. Personally, I have heretofore used 
the straight bistoury from the beginning to the end of the operation, 
with great satisfaction. I must, however, confess that Sluder's method 
is simpler, safer, and better in every way, though it cannot be used 



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OPERATIONS ON THE TONSILS 431 

in more than 75 per cent, of the cases. Most laryngologists separate 
the pillars with scissors or peculiar angular knives, and then place a 
wire snare over the tonsil and pull it through the loop and complete the 
operation with the snare. 

All of these methods are practical, and are to be commended, because 
they accomplish the necessary result — namely, the complete removal of 
the tonsil with its capsule intact, as first advocated by me in 1898. Until 
five years ago there was much opposition to my contention for com- 
plete tonsillectomy, whereas it is now almost universally adopted by 
American laryngologists. 

Fig. 291 -" 




Sluder's tonsil operation. First step. 

It must be admitted that tonsillectomy has more "terrors" -for the 
laryngologist than tonsillotomy ever had, and the reasons are not difficult 
to discover. Tonsillotomy was formerly performed chiefly upon young 
children, rarely upon adults. 

Both tonsillotomy and tonsil- Fig. 292 

lectomy are more serious pro- 
cedures in adults — hence, one 
reason for the increasing dread 
of tonsil operations. Another 
and more important reason is, 
that, whereas, formerly the 
operator depended almost ex- 
clusively upon the guillotine 
and tonsillotome (semi-auto- 
matic instruments), he now 
depends upon knives and scis- , . ., . , ., ,. . . , , , ., 

1 . 1 . becond step: the tonsil dislocated lorward over the 

sors which require much more tubercle areolaris. 

personal dexterity and so-called 

surgical skill for their successful use. With these instruments, the mus- 
cular bed of the tonsil is often injured and the bleeding more profuse in 
consequence. 

Dr. Greenfield Sluder has attempted to restore order where chaos 
existed, confidence where fear reigned, and simplicity in place of com- 
plexity — all, by the return to the use of the guillotine in the removal 
of tonsils. By his method, the guillotine no longer merely decapitates 
the tonsil, but removes it with its capsule intact. 






432 



THE PHARYNX AND FAUCES 



Rationale. — Heretofore the objection to the removal of the tonsil 
with the guillotine and tonsillotome was that neither would remove 
the entire gland — it was only decapitated or partially removed. The 
simplicity of the technique required in the use of these instruments made 
them very popular, and they were almost universally adopted. When 
the modern movement for the "complete removal of the tonsil with its 
capsule intact" became the rule of practice, the guillotine and tonsillo- 
tome were relegated to the vast heap of discarded instruments. Most 
laryngologists will gladly restore the guillotine to the list of useful 

Fig. 293 





/ 



Third step of Sluder's operation: pushing the tonsil through the fenestra of the guillotine. 

instruments when they learn that with it they can remove the tonsil in 
its entirety in as few seconds as was formerly required to decapitate it. 
The complete enucleation of the tonsil will have lost many of the 
modern terrors, and will assume its former place as one of the simpler 
and comparatively safe surgical procedures if Sluder's operative tech- 
nique is adopted. The hemorrhage in Sluder's operation under ether 
anesthesia is considerable, though it is oozing in character, rather than 
spurting. This feature can no doubt be overcome by the preliminary 
injection of adrenalin. In all my cases operated by his method, not 



OPERATIONS ON THE TONSILS 433 

a shred of muscular tissue has been removed, a point of great importance 
in operating upon singers. Apparently the only tissue cut was the 
mucous membrane of the two pillars at their junction with the tonsil. 
The muscular bed upon which the tonsils rested seemed to have been 
separated from the capsule of the tonsil without the slightest injury 
to the muscular tissue. Another fact has impressed me, namely, that 
not infrequently little or no soreness in the throat follows the opera- 
tion in children. The reason is obvious; the only tissue incised was 
the mucous membrane, while the tonsil capsule was separated from the 
muscular tissue without trauma. 

The fundamental facts underlying Sluder's technique are three in 
number, namely: (a) The guillotine will remove the tonsil with its 
capsule intact, provided the tonsil is pushed through the fenestra of the 
instrument. The advisability of pushing the tonsil through the fenestra 
of the guillotine has long been recognized, as is exemplified by the oft- 
repeated advice to exert pressure under the angle of the jaw during the 
removal of the tonsil. This manipulation was, however, rarely attended 
with success. 

(b) The sinus tonsillaris (bed of the tonsil) is freely movable, allow- 
ing the tonsil to be dislocated forward and upward a distance of about 
one and one-half inches. 

(c) At a distance of one and one-half inches anterior and superior to 
the tonsil is located a bony prominence on the inferior maxilla, called 
by Sluder the eminentia alveolaris. This eminence corresponds to the 
location of the last molar tooth (Fig. 296, a). 

These facts are put to practical use in the Sluder operation. The 
tonsil is displaced forward and upward over the tubercle, which in turn 
pushes it through the fenestra of the guillotine; the guillotine blade 
is then pushed home, removing the tonsil with its investing capsule. 

Technique. — (a) In the removal of the right tonsil, the patient in the 
upright position, the Sluder guillotine is grasped by its handle with the 
operator's right hand and introduced through the left angle of the mouth 
until the distal portion of the fenestral margin is in contact with the 
inferior and posterior portion of the tonsil. 

(6) The instrument is then pressed firmly against the tissues, which 
are drawn forward and upward for a distance of about one inch. The 
tonsil then rests over the eminentia alveolaris, which pushes the tonsil 
through the fenestra of the guillotine (Fig. 292), though it may not 
push it all through the opening. If the blade of the instrument were 
forced home at this stage of the procedure, the tonsil would not in 
all probability be removed in its entirety, with its capsule intact. 
Instead, only the superficial portion of the tonsil would be removed. To 
obviate this mishap, the tonsil is drawn a little farther forward until 
the distal margin of the fenestra rests almost upon the apex of the 
eminence. The handle of the instrument is then slightly depressed, to 
bring the inferior portion of the margin of the fenestra in firm contact 
with the inferior portion of the tonsil. This leaves the tonsil exposed to 
view (Fig. 291). The left index finger is then used to push the tonsil 
28 



434 THE PHARYNX AND FAUCES 

through the fenestra (Fig. 292). The blade of the guillotine should, 
however, be gently pressed against the anterior portion of the tonsil, 
to hold it in position while the balance is being pushed through the 
fenestra with the tip of the left index finger. 

(c) In the third step of the operation the remainder of the tonsil is 
pushed through the fenestra with the tip of the left index finger (Fig. 
293). As the tonsil continues to pass through the fenestra, the blade 
of the instrument is advanced by gentle pressure with the thumb of 
the right hand. 

The tonsil tissue is readily detected by the sense of touch, as it is firm 
and nodular, whereas, the mucous membrane is soft, thin, and smooth in 
texture. When the tonsil is completely through the fenestra of the instru- 
ment, only the smooth, thin mucous membranes of the anterior and 
posterior pillars lie between the tip of the finger and the distal margin 
of the fenestra. The blade is at this time advanced until only the two 
mucous membranes lie between its cutting edge and the distal margin 
of the fenestra. 

(d) The blade is then forced home, with considerable power, both 
hands often being required for this purpose if the blade is dull 

This completes the removal of the right tonsil. 

Position of the Surgeon in Relation to the Patient. — When the patient 
is in the upright position, the left tonsil is removed with the guillotine 
grasped in the left hand, the index finger of the right hand being used 
to force the tonsil through the fenestra of the guillotine. In all other 
respects the technique is the same if the operator is ambidextrous. If 
he is not ambidextrous, that is, can only use the instruments with one 
hand (the right), he will have to change his relative position to the patient 
in operating upon the left tonsil. If the patient is in the sitting posture, 
the operator will stand to the right and a little behind the patient, and 
lean forward over his head to remove the left tonsil. 

When the patient is lying face upward upon a table and the operator 
is standing, he should stand on the right side of the patient, facing the 
head of the patient, to remove the right tonsil; to remove the left tonsil, 
the operator should stand at the head of the patient facing his feet. 
In this way the guillotine may be held in the right hand for the removal 
of both tonsils. The right tonsil is removed with the instrument in 
the right hand, the left index finger pushing the tonsil through the 
fenestra. The left tonsil is removed by the guillotine in the right 
hand, the left index finger pushing the tonsil through the fenestra. 
The surgeon stands on the right side of the patient and faces him. 

Instrumentarium.— The only instrument required for this operation 
is the Sluder guillotine. The McKenzie or other models of the guillo- 
tine are not properly constructed for this operation, as the distal face 
of the fenestra must be applied to the tonsil in order to keep the handle 
of the instrument and the operator's hands from obstructing the view 
of the field of operation. A casual examination of the other models of 
the guillotine will readily demonstrate their unfitness to stand the 
pressure exerted in dislocating the tonsil forward and upward over the 



OPERATIONS ON THE TONSILS 



435 



eminentia alveolaris. Sluder's instrument and my modification of it 
have shorter and heavier shanks, especially constructed to withstand 
the pressure necessarily exerted in this operation. 




The author's tonsillectome with sharp blade and scissors-handle. 

Since the third edition of this work I have removed many hundreds 
of tonsils by the Sluder method, though a somewhat different technique 
was employed. I have modified the guillotine by adding a scissors- 
handle (Figs. 294 and 295), which greatly facilitates the work and 

Fig. 295 




The author's tonsillectome with dull blade, equal to No. 1 piano wire. This instrument drives 
the blade home with three closures of the scissors handle, and is designed to replace the tonsil snare. 

requires very much less muscular power to cut through the tissues. 
Fig. 294 is supplied in two sizes, and has a sharp blade. Fig. 295 is sup- 
plied with a dull blade of the thickness of a No. 1 wire, and is designed 



436 THE PHARYNX AND FAUCES 

to take the place of the wire snare. The use of the dull instrument is 
attended by less hemorrhage than the sharp one. The dull instrument 
works with a rachet device and has great power; the sharp instrument 
works with direct power from the scissors-handle. I now pull the 
tonsil against the tip of my finger instead of the alveolar eminence, 
suggested by Dr. Sluder. This accomplishes the same purpose and 
simplifies the whole procedure. 

Present Technique. — Introduce the tonsillectome (either Fig. 294 
or 295) as heretofore described (Plates "XII, XIII and Fig. 291) and 
engage the tonsil with the distal rim of the fenestra! ring. Then intro- 
duce the index finger of the disengaged hand into the mouth of the 
patient, against the anterior pillar. Drag the tonsil forward and 
above the inferior molar teeth against the ball of the tip of the index 
finger. The finger holds the tonsil in the fenestra of the instrument, 
and at the same time pushes it through it. When the tonsil is through 
the fenestra close the scissors handle and drive the blade home. If 
the dull-bladed instrument is used three movements of the scissors- 
handle are required to send the blade home. As the blade "goes 
home," the two pillars are brought together external to the tonsil 
and severed from their attachment to it. The whole procedure need 
require but a few seconds or a minute at the most in a suitably selected 
case. Fully 75 per cent, of all cases, including adults, are operable by 
this method. Sluder claims 99 per cent, of successes by it. 

Contraindications to the Sluder Operation. — 1. Deep adhesions of 
the tonsil to its muscular bed, especially found in cases previously 
subject to quinsy or repeated severe anginas. When such adhesions 
are present it is difficult or impossible to drag the tonsil from the 
sinus tonsillaris against the finger. 

2. Very thin flat tonsils are not suited for removal by this method, 
as there is not enough substance or bulk to them to allow the instru- 
ment to readily engage them. 

Tonsillotomy. — The author has elsewhere expressed his views as to 
the inadvisability of removing a portion of the tonsil, but inasmuch 
as it is a time-honored procedure, and is likely, for various reasons, to 
be practised in the future, it will be described in this chapter. 

Technique. — (a) The operation maybe done under either local cocaine, 
infiltration, or general anesthesia. 

(b) If the subject is an infant or a young child, and the operation 
is to be performed under either local or nitrous oxide gas or bromide of 
ethyl anesthesia, he should be held in the lap of an assistant. He should 
be wrapped in a sheet tightly pinned around his body and one arm, 
while his head should be grasped by the assistant's left arm and hand. 
The legs of the assistant should be crossed over those of the child, to 
prevent struggling during the operation. If a general anesthetic is 
administered, one arm should be left exposed to test the pulse and the 
muscular reflexes. 



OPERATIONS ON THE TONSILS 437 

(c) A mouth gag may or may not be used, according to the dis- 
cretion of the operator. 

(d) Depress the tongue with a tongue depressor, to expose the tonsil 
to full view. 

(e) Introduce the tonsillotome into the mouth of the child, place the 
ring blade over the tonsil and forcibly push it outward, and at the same 
time bring the ring: blade forward to engage the tonsil. 

(/) When the tonsil protrudes through the ring blade, close the instru- 
ment and thus cut off as much of the tonsil as happens to protrude 
through it. 

It occasionally happens that the entire tonsil with its capsule intact is 
removed by this method of operating. More often only a portion of it 
is removed. The upper portion is often quite inaccessible to the ring 
knife, and as this usually contains the more diseased crypts, the operation 
is but partially effective. 

Complications and Sequelae of Operations on the Tonsils. — Inas- 
much as tonsillectomy is, or should be, performed as often in adults as 
in children, the question of postoperative hemorrhage and of infection 
becomes an important one. In children hemorrhage and infection of 
a severe type are rare, whereas in adults they are much more common 
on account of the larger development of the vessels and the greater 
abundance of fibrous connective tissue, which offers less resistance to 
microbic infection. 

Hemorrhage. — (See page 392.) 

Infection. — The infection following operations on the tonsils is usually 
more severe and prolonged in adults than in children. In children 
the temperature is elevated 0.5° to 2° for two or more days, whereas in 
adults it is often more highly elevated for from two days to a week 
or more. The soreness in children is usually limited to three or four 
days, while in adults it often continues longer. If the infection were 
only thus manifested, it would be a matter of small importance. Un- 
fortunately, it is occasionally so severe as to be alarming, even to the 
point of actual danger to life itself. While I have never seen a case result 
in death, I have seen a few assume alarming symptoms. That is, I have 
seen two, in about 9000 cases, in which the hemorrhage was so prolonged 
that marked anemia and exhaustion resulted, and two of severe sepsis 
from streptococcus infection. 

If the cases with secondary hemorrhage had been operated upon in the 
hospital, the bleeding could have been more quickly controlled and the 
danger averted, or, indeed, it might not have occurred, as the patients 
would have remained quiet in bed. 

In one of the septic cases the tonsils were removed by partial dis- 
section and completed with a snare, whereas in the other case the dis- 
section was done with a sharp scalpel. In the latter case the infection 
was the more severe of the two, a fact which apparently controverts 
my previous statement that a clean-cut dissection is less apt to be followed 
by infection than a dull-cut or crushing dissection with a snare. In spite 
of the apparent discrepancy, I wish to reaffirm my previous statement 



438 



THE PHARYNX AND FAUCES 



Fig. 296 



that dissection with a sharp instrument is less likely to be followed by 
severe secondary infection than one done with dull-cutting or crushing 
instruments. Another factor which must be taken into account is the 

virulence of the infective microorganism 
causing the infection. If a virulent type 
of streptococcus is the infective agent, the 
resulting infection and sepsis will be severe, 
no matter what method of dissection is 
used. Crushed tissue is less resistant than 
tissue cut with a sharp instrument, hence 
it is more readily infected, though either 
may be the seat of infection. The whole 
question is one of the microorganism on 
one side and of the tone or resistance of 
the tissues on the other. If the resistance 
of the tissue is normal and the virulence of 
the microorganisms are great, infection will 
follow. If the resistance of- the tissue is 
low and the virulence of the microorganism 
is low, there may or may not be infection, 
according to the balance or lack of balance 
existing between the resistance of the 
tissues and the virulence of the infecting 
microorganisms. It follows, therefore, that 
the question of infection is not wholly de- 
pendent upon whether the dissection is 
performed with blunt or with sharp instru- 
ments, but that the general tone of the 
tissues previous to the operation, the local 
tone as affected by either blunt or sharp 
instruments, and the virulence of the 
invading microorganism each has its influ- 
ence in determining the severity of the 
infection and the resulting sepsis. 

The practical deductions to be drawn from 
the foregoing statements are as follows: 

1. If the patient's vital forces are low, 
tonics and fresh air should be prescribed 
operation. It is true that it is not often 
advisable to delay the removal of the tonsil until the general tone of 
the system is elevated, as the tonsils may be the direct cause of the 
lowered vitality of the patient, and should be removed to stop the 
toxemia. Under such circumstances the risk of the infection and 
sepsis must be assumed, and such measures adopted as will avert or 
minimize the intensity of the two processes. 

2. The resistance of the tissues is influenced by the previous local 
disease and by the character of the dissection. The local changes 
due to previous disease of the tonsil cannot, perhaps, be eliminated, 




Right half of inferior jaw, showing 
(a) the eminentia alveolaris. 

for some time before the 



OPERATIONS ON THE TONSILS 439 

and, in so far as this factor is concerned, the operation must be per- 
formed in spite of them. In so far as the tone of the local structures 
is affected by the character of the dissection, this is entirely under 
the control of the operator. He can avoid the use of crushing instru- 
ments by substituting sharp ones. While this precaution will not 
always prevent infection and sepsis, it will reduce the number and 
severity of the infections. 

3. The virulence of the microorganisms in the throat may be deter- 
mined before the operation by the adoption of the routine practice 
of making ■ cultures from the tonsils. This is not always practic- 
able, but when it is, it should be done. Another way of arriving at 
much the same result is to carefully inspect the tonsil, especially the 
crypts in the supratonsillar fossa and those covered by the plica tonsil- 
laris, and note the local signs of irritation and inflammation, especially 
redness of the mucous membrane. Still further information may be 
obtained by questioning the patient as to the presence of soreness or 
pricking upon swallowing. If these signs are present, it is wise to 
defer the operation until the crypts are cleaned out and the local 
irritation and inflammation have subsided. 

Fig. 297 






Tonsils removed by Sluder's method. (Sluder.) 

There is a possibility that severe infection may follow the removal 
of the tonsil, even in cases in which there is no apparent inflammation. 
Virulent germs may be lodged in the bottom of the crypts without 
giving rise to obvious symptoms. Close inquiry may elicit the state- 
ment that the patient has a slight soreness upon swallowing, a sensation 
of pricking. In one such case in the author's practice a most violent 
and obstinate infection occurred. The patient, a rhinologist, came for 
the removal of his tonsils, and inasmuch as I presumed that he knew 
whether his throat was in a proper condition for the operation, the 
tonsils were removed. After the occurrence of the infection he told me 
that he had been suffering for a week from a slight soreness or pricking 
in the throat. These facts show that the surgeon should not presume 
anything, even though the patient is supposedly well informed con- 
cerning his condition. All cases should be subjected to close scrutiny 
by the surgeon before performing an operation. 

Should the examination show such soreness to be present, the opera- 
tion should not be performed. The crypts of the tonsils should be 



440 



THE PHARYNX AND FAUCES 



cleansed of all debris by syringing (Fig. 299) with warm normal salt 
solution. A curved cotton applicator moistened with the tincture of 
iodine should be introduced into each crypt to allay any infection and 
inflammation in them. Treatment thus carried out for one week will 
usually prepare the tonsils, so that the operation may be performed 



Fig. 298 




Reverse Trendelenburg position for the removal of tonsils. 



without the danger of infection of tonsillar origin. It is urged, therefore, 
that the surgeon should always prepare the tonsils for operation, just 
as he would any other part of the body. The same rule should be 
applied to the nose, throat, and larynx, even though these regions are 
not susceptible to absolute surgical cleanliness. The breeding or 
incubating foci can at least be eradicated. 



OPERATIONS ON THE TONSILS 441 

Is Tonsillectomy a Hospital Operation? — In young children it is not 
necessarily a hospital operation, because it is rarely followed by either 
severe hemorrhage or sepsis. In adults it should be a hospital operation, 
on account of the possible hemorrhage and sepsis. 

A prominent surgeon has said that the tonsil is of greater clinical 
importance than the appendix ; that it causes more suffering and more 
deaths. If this is true, and I believe it is, the tonsil is worthy of the 
most serious and painstaking study. 

Fig. 299 



The author's tonsil syringe. 

The technique of its removal should receive the same careful and 
patient attention that has been devoted to the removal of the vermiform 
appendix. In view of the importance of the tonsil from a clinical stand- 
point, and in view of the possible complications and sequelae following 
its removal, tonsillectomy should be regarded as a hospital operation. 
If performed in a hospital, the danger from primary or secondary hemor- 
rhage is largely eliminated, and infection and sepsis may be diminished 
in severity and in the frequency of their occurrence. 

George L. Richards and Charles Richardson advocate the complete 
removal of the tonsil by finger dissection. The pillars are partially 
separated with a knife of some description, the finger inserted into the 
incision and the tonsil separated from the sinus tonsillaris. The fibrous 
pedicle at the root of the tongue is then severed with a snare or tonsil- 
lotome. While this method of enucleation is old, it has awakened new 
interest on account of the enthusiastic indorsement of these eminent 
and practical laryngologists. 



CHAPTER XXIV 

NEOPLASMS OF THE TONSIL 
BENIGN NEOPLASMS OF THE TONSILS 

Benign tumors do not occur as often in the tonsils as they do elsewhere 
in the pharynx. Of the variety found in this region, papilloma is the 
most common. 

Papilloma. — Papilloma is more often multiple than single, and presents 
the general outlines of a bunch of grapes. If single and large, it may 
be mistaken for a supernumerary tonsil. Like all papillomata, it has 
a tendency to return, and is sometimes apparently converted into a 
malignant growth. It should, therefore, be removed by clean surgical 
excision, rather than by a crude crushing method, as with a snare or dull 
forceps. It should be borne in mind that the transition from a benign 
papilloma to a malignant epithelioma is, histologically, rather easy. The 
epithelial growth in the papilloma is outward, whereas in epithelioma 
it is inward. There are, of course, other histological differences. The 
structural arrangements are, however, so similar as to warrant a certain 
amount of caution and discretion in their diagnosis and surgical treatment. 

In some instances there may be one pedicle with many papillomata 
attached, whereas in others there may be many pedicles. 

The growths, as a rule, give rise to no marked symptoms. A slight 
hacking cough, a tickling sensation, and the feeling of a foreign body in 
the faucial region are complained of. The only change noted in the 
surrounding tonsillar tissue is an increased hyperemia around the attach- 
ment of the tumor. Pain is never present. The tumors vary in size 
from that of a pea to a large walnut. 

Lipoma. — Lipoma of the tonsil is rare, though Atkinson, Farlow, 
Ingals and others have reported cases. They are benign fatty tumors. 

Angioma. — Angioma of the tonsil is also quite rare. Flatau, Phillips, 
Bosworth, Keimer and others have reported a few cases. 

Treatment. — The treatment is preferably by electrolysis. The positive 
pole should be applied by means of gold-plated needles thrust into the 
neoplasm. The strength of the current should vary from 5 to 25 ma., and 
should be applied for from two to twenty-five minutes at each seance. 
Repeat the applications once or twice a week until the vascular growth 
is obliterated. 

Fibroma. — Fibroma of the tonsil is a benign neoplasm next in fre- 
quency of occurrence to papilloma. It very rarely becomes malignant. 
Its growth is very slow, and is usually limited to one tonsil. Delevan 
and others have suggested that fibrous tumors of the tonsils may be 
(442) 



BENIGN NEOPLASM OF THE TONSILS 443 

mistaken for supernumerary tonsils. This is especially true if the super- 
numerary tonsil acquires its fibrous tissue from the degenerative changes 
due to a constant irritation from its exposed position in the fauces. Tech- 
nically, it is a fibroplastic fibroma. Some claim that it is only a fibroma 
which incorporates some of the lymphoid tissue of the tonsil. 

Etiology. — Fibroma of the tonsil occurs equally often in each sex, and 
perhaps more often in the young than in middle and advanced life. 

Pathology. — Fibroma is usually somewhat pedunculated, though it 
may be sessile. The larger the fibroma, the larger the pedicle. It is 
more often single than multiple. Being of connective tissue of meso- 
blastic origin, it must of necessity have its origin from the trabecular 
of the tonsil. Occasionally it undergoes cystic degeneration. Usually 
it is firm and scantily supplied with bloodvessels. It is composed of 
white fibrous tissue, the cells often being matted together, closely simu- 
lating embryonic connective-tissue cells. 

Symptoms. — Annoying symptoms are seldom present, except in the 
large pedunculated type, in which it produces mechanical obstruction. 
Its presence is not accompanied by discharge. It is characterized by 
symptoms similar to those of enlarged or hypertrophied tonsils. 

Diagnosis. — The diagnosis is usually easily made, and in case of doubt 
a portion should be excised and submitted to microscopic examination. 

Treatment. — The treatment is purely surgical, and consists in its re- 
moval, a procedure easilv accomplished if the growth is pedunculated. 
Occasionally it may be adherent to the tonsil or to the neighboring 
structures as a result of repeated inflammations of the tonsil. 

Surgical Technique. — (a) Cocainize the growth and the area around 
the point of attachment with a 10 per cent, solution of cocaine by 
repeated swabbings. 

(6) Separate the points of adhesion with a scalpel or scissors. 

(c) Pass a cold-wire snare around the tumor, engaging it at its pedicle, 
or point of attachment. 

(d) Sever the pedicle by closing the wire loop. 

(e) Cauterize the stump of the pedicle, and if it penetrates the tonsillar 
tissue, dissect it to its point of origin. 

(J) Frequent cleansing with some antiseptic gargle should be practised 
for about one week, or until healing takes place. 

(g) Instead of using the wire snare as given in (c), the growth may be 
seized with the vulsellum or other toothed forceps and dissected with 
a scalpel from its attachment to the tonsil, or the tonsil may also be 
removed. 

Fibro-enchondroma. — A few cases have been described, and notable 
among them is that of Cosolini, in which the growth was as large as an 
orange, and was readily enucleated. Grosvenor also reported one case. 

Cystoma. — Cystoma of the tonsil is rare. It may be either super- 
ficially or deeply situated. Virchow reports having found them post- 
mortem. I have occasionally found them of small size when enucleating 
hypertrophied tonsils. They vary in size, and may contain a quantity 
of fluid or a mass of inspissated secretions and epithelial debris. 



444 THE PHARYNX AND FAUCES 

They give rise to no peculiar symptoms other than those usually 
present in enlarged tonsils. 

They may be eradicated by freely incising them with a bistoury and 
curetting the lining membrane, and then swabbing the cavity with pure 
carbolic acid to excite reactionary inflammation and agglutination of 
the opposed walls. A still better method of treatment is to enucleate 
the tonsil as described under Tonsillectomy. 

Lymphadenoma in Hodgkm's Disease. — In every case of Hodgkin's 
disease, it is advisable to examine the tonsils, as they may be the seat 
of a lymphadenoma such as is present in other parts of the body. In 
the early stage of the disease it may be impossible to assert positively 
that the tonsils are involved, though they may appear abnormally en- 
larged. In the author's case the tonsils did not appear to be enlarged. 
By keeping the case under observation their growth may become ap- 
parent, and when it occurs is quite significant. Lymphadenoma of 
the tonsil is only a local expression of a disseminated lesion of a similar 
nature throughout the general lymphatic system. In my case the tonsils 
were not apparently involved, though the neck glands were enormously 
enlarged. The case improved markedly under the application of the 
Rontgen rays. 

MALIGNANT NEOPLASMS OF THE TONSILS 

Carcinoma of the Throat. — According to some authorities carcinoma 
is more frequently found in the tonsils than sarcoma, while others hold 
the reverse opinion. More than 100 cases have been recorded, and, 
according to Bosworth, it occurs once in every 2000 cases of carcinoma 
in all parts of the body. It is a disease of middle and advanced age, 
though J. D. Bryant reports a case in a patient aged seventeen years. 
Sarcoma may occur at any age, but more often in early life. The young- 
est case coming under my observation occurred at the eighteenth month. 
Cases of sarcoma have been reported as late as the eightieth year. The 
average age at which carcinoma develops is about the fifty-second year. 

Carcinoma of the tonsil is more malignant than sarcoma because of 
the histopathological predominance of glandular epithelium. It is 
rarely primary, but is usually secondary to carcinoma of the tongue or 
pillars of the fauces. It is usually characterized by a squamous and 
spindle-cell epithelium. It does not attain the large size of sarcoma of 
the tonsils, but it involves the neighboring lymphatic glands at an 
earlier period. 

Symptoms of Carcinoma. — Early ulceration, a fetid breath, more or less 
pain of a lancinating character, emaciation, and cachexia are the usual 
symptoms. Before ulceration the secretions are of a heavy mucous 
nature, while after ulceration they are often purulent in character. Slight 
hemorrhage is a frequent symptom. It may, however, in exceptional 
cases, be very profuse and cause death. Edema of the glottis is frequently 
present; indeed, one might say it is an almost constant concomitant 
complication of carcinoma of the tonsil in the advanced stage. 



EXTIRPATION OF THE TONSIL BY THE EXTERNAL ROUTE 445 

Pain is always aggravated during the act of swallowing, and the voice 
is either hoarse or aphonic. Secondary glandular involvement is an 
early feature. The subjective symptoms are very little different from 
those of sarcoma of the same region, except in the advanced stage, when 
ulceration and pain are present. 

Diagnosis. — Carcinoma of the tonsil is a disease of middle and advanced 
life, while sarcoma more often occurs in the young. Ulceration occurs 
early in carcinoma and later in sarcoma; carcinoma is nodular, while 
sarcoma is smooth and round. Carcinoma has a fleshy pink hue and 
is often fungoid, while sarcoma is blue in color and is crossed by rather 
large arteries. 

When in a state of ulceration carcinoma may be mistaken for syphilis, 
particularly if the adjacent glands are not much involved. 

The progress of the case and the administration of the iodides will 
soon clear the diagnosis. 

The pain in carcinoma is lancinating and sharp, while it is dull and 
periodic in sarcoma. 

Papilloma is painless, pedunculated, seldom ulcerates, and secondary 
involvements by direct extension of metastases do not occur. There are 
no constitutional symptoms, and the growth is multiple and presents 
the appearance of a bunch of grapes. 

Fibroma of the tonsil has a constricted base, grows very slowly, is 
free from pain and glandular involvement, and does not recur when 
removed. 

A microscopic examination of the tissue should be made in differen- 
tiating the various types of tumors. 

Differential Diagnosis of Sarcoma and Carcinoma of the Faucial Tonsils 

Sarcoma Carcinoma 

1. Any age, most often after fifteen. 1. Not in early life, usually after forty. 

2. Frequently primary. 2. Rarely primary. 

3. Glandular involvement late. 3. Glandular involvement early: 

4. Frequently encapsulated. 4. Not encapsulated. 

5. Vascular; hemorrhages; ulcerates late. 5. Not so vascular; scant hemorrhage; 

ulcerates early. 
6. Frequent in males. 

Treatment. — The treatment of carcinoma and sarcoma of the tonsil is 
palliative and surgical, though in most cases the latter affords little 
encouragement. 



EXTIRPATION OF THE TONSIL BY THE EXTERNAL ROUTE 

In malignant disease of the tonsils where the surrounding tissues have 
become involved, it may become necessary to remove the tonsil by the 
external route by von Langenbeck's method. 

Technique. — (a) A general anesthetic should be given. 

(b) The external incision is in the form of a IT, thus making a tongue- 
shaped flap (Fig. 300). The flap thus made lies immediately over the 



446 THE PHARYNX AND FAUCES 

ascending ramus of the lower jaw. This portion of the jaw is to be 
temporarily resected, so as to expose the tonsillar region to operation. 

(c) The external maxillary artery (facial) is ligated to control the 
hemorrhage. 

(d) The periosteum corresponding to the anterior incision should be 
divided preparatory to sawing through the bone. 

(e) The jaw bone is sawn through along the line of the periosteal 
incision just in front of the insertion of the masseter muscle. 

(J) The connective-tissue attachments of the ascending ramus of the 
jaw on its inner surface are then carefully dissected from the bone, care 
being exercised to avoid injuring the muscles of mastication. 

(g) The ascending ramus of the jaw is then lifted outward and up- 
ward, thereby exposing the region of the tumor to view (Fig. 300). 

Fig. 300 




Temporary resection of the ramus of the inferior maxilla to expose the fauces in 
the removal of malignant tumor of the tonsil. 

(h) The tumor is then exposed by dissection. The external carotid 
artery lies externally and posteriorly. 

(i) The tumor should be removed with knife and scissors, care being 
exercised to avoid opening into the cavity of the mouth until the last 
moment, so as to keep the secretions from entering the wound. 

(j) The ascending ramus of the jaw is then returned to its normal 
position and sutured with wire. 

(k) The skin is then sutured with horsehair or with Harris' buried 
suture. 

(/) The wound is dressed through the mouth, healing taking place 
by granulation, as after an ordinary tonsillectomy. 



PART III 
DISEASES OF THE LARYNX 



CHAPTEE XXV 

INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS 
ACUTE INFECTIOUS EPIGLOTTITIS 

Synonyms. — Angina epiglottidea anterior (Michel); acute infectious 
epiglottitis (Theisen). 

The disease is often primary, and is an acute infectious process. Clem- 
ent F. Theisen reports three cases, and gives a most admirable review 
of the literature on the subject. Michel, in 1878, first described an 
inflammatory process, involving the anterior surface of the epiglottis, 
under this name. It is usually accompanied by more or less circumscribed 
edema. While the larynx may be somewhat involved in some cases, 
Theisen claims that true angina epiglottidea occurs quite often as a 
primary, separate, distinct condition. 

Etiology. — In the diffuse type of inflammation the epiglottis may 
become inflamed by an extension from acute tonsillitis, pharyngitis, or 
lingual tonsillitis. In the true primary type its origin is not thus ex- 
plained. In the cases reported by Theisen there was no history of coryza, 
or other acute infectious condition of the upper respiratory tract. The 
larynx was but slightly involved. The ages of the patients were thirty- 
six, forty, and fifty-nine years respectively, one male and two females. 
Hajek's experiments show that the submucosa of the anterior surface 
of the epiglottis is abundant and the mucosa loosely adherent, while 
on the laryngeal surface it is tightly adherent to the cartilage except 
at the nodules, where there is some loose submucous tissue. These 
anatomical facts explain why the edema does not extend to the larynx, 
as one might at first expect it would do. In excessive edema it may, 
however, extend to the larynx by way of the submucous tissue of the 
pharyngo-epiglottic ligament, thence to the ary epiglottic folds. Injury 
to the epiglottis or the neighboring tissue by swallowing foreign bodies 
or irritating substances may cause the condition. Hot drinks, raw 
spirits, or highly spiced liquids may also be regarded as possible predis- 
posing etiological factors. In edema of the fauces due to large doses of 

(447) 



448 DISEASES OF THE LARYNX 

the iodide of potash, the epiglottis may become involved. The infectious 
fevers are also likely to give rise to this distressing condition. 

Perichondritis, carcinoma, and ulcerative conditions due to syphilis 
or tuberculosis may suddenly become complicated by it. 

Bacteriological examinations made in two of Theisen's cases showed 
Streptococcus aureus and pneumococcus in one and Staphylococcus 
albus and pneumococcus in the other. The atrium of infection in some 
instances seems to be a traumatic wound, in others it is an extension of 
an acute inflammation from contiguous anatomical parts, and in a third 
class it is a malignant tuberculous or syphilitic ulcer. The chief cause, 
then, is a mixed infection, which may or may not be preceded by a gross 
lesion of the anterior surface of the epiglottis. 

Pathology. — From what has been given under Etiology and Symp- 
tomatology, it may be inferred that the pathology is such as is common 
to acute inflammation of mucous membranes covering loose submucous 
tissue. This consists of inflammatory congestion, exudation, and edema, 
which processes, in typical cases, are limited to the anterior surface of the 
epiglottis. The bacteriological infection is usually the pneumococcus 
with the Streptococcus aureus or the Staphylococcus albus. 

Symptoms. — The onset is sudden, and attended with fever, painful 
deglutition, stiff, swollen tongue, and dyspnea, especially upon lying 
down. In one case reported by Theisen, the latter symptom was so 
severe as to necessitate propping the patient up in bed. 

The febrile symptoms are similar to infectious fevers in general. 

Upon examination, the anterior surface of the epiglottis is red and 
swollen, while the adjacent tissues are usually but little, if at all, involved. 
These symptoms continue with more or less severity for five or six days, 
when they abate in intensity; the epiglottis, however, remains red and 
swollen a few days longer. 

Diagnosis. — If certain characteristic symptoms are borne in mind, 
there need be but little difficulty in arriving at a correct diagnosis. These 
symptoms are: (a) Sudden onset, (b) A febrile movement, (c) Red- 
ness and swelling limited to the anterior or lingual surface of the epi- 
glottis, (d) More or less painful deglutition. 

Acute angioneurotic edema is unattended by fever, and the edematous 
tissue is pearly gray instead of red. 

It should be differentiated from acute miasmatic epiglottitis, which 
follows exposure to salt marshes, as in hunting for ducks on the mud 
flats of the California coast. Arnold has described this condition in 
Burnett's system on the Xose, Throat, and Ear. (See Acute Miasmatic 
Epiglottitis.) 

Prognosis. — The prognosis in most cases is good, although deaths 
have been reported by Tompkins, Louis, Gibb, Crisp, and Fredet. 
Proper treatment exerts a favorable influence upon its course. 

Treatment. — Early scarification of the edematous parts gives prompt 
relief in some instances. It should be done freely. Meyjer recommends 
the use of iced ichthyol sprays, which are prepared by putting cracked 
ice into the spray tube containing the ichthyol solution. Theisen speaks 



ACUTE CATARRHAL LARYNGITIS 449 

of using a 0.5 per cent, solution of iehthyol every twenty to thirty minutes 
while the acute symptoms continue, and at longer intervals afterward. 
It is important to give early relief, as the patient may not be able to 
swallow even liquid food until this is done. Calomel and salines may 
be given advantageously at the onset. 

The physician should be prepared to do tracheotomy at any moment, 
as suffocative symptoms may suddenly develop. 



MIASMATIC EPIGLOTTITIS 

Arnold, in Burnett's System, describes an acute inflammatory process 
which chiefly involves the epiglottis. It is attended by marked edema 
of the epiglottis, painful swallowing (odynophagia), and dyspnea. 

Etiology. — He attributes the cause "to some animal, vegetable, or 
chemical poison in the exhalations of the salt marshes." He describes 
six cases, all of which were men who had returned from hunting ducks 
on the mud flats of the salt marshes on the California coast. It is 
probable that the cases were due to a mixed infection from some nidus 
of propagation in the marsh country along the coast. Whether the cases 
should stand apart as illustrative of a separate and distinct disease is 
perhaps doubtful. 

Symptoms. — Epiglottic edema and inflammation may be severe, and 
the adjacent structures somewhat involved. There is odynophagia and 
dyspnea. In one case the suffocative symptoms became so alarming 
that tracheotomy was performed. Pyrexia is more or less marked. 



ACUTE CATARRHAL LARYNGITIS 

Synonyms. — Catarrhal laryngitis; acute catarrh of the larynx; simple 
laryngitis; laryngitis catarrhalis acuta. 

Acute catarrhal laryngitis is an acute catarrhal inflammation of the 
laryngeal mucosa and of the vocal cords. It is characterized by hoarse- 
ness or aphonia, and pain upon phonation. 

Etiology. — The etiology of acute catarrhal laryngitis may be studied 
under: (1) Systemic disturbances and diseases; (2) preexisting diseases 
of the upper respiratory tract; (3) hygienic conditions and environment; 
(4) traumatism; (5) age; (6) climate; (7) idiopathic causes. 

1. Systemic Disturbances. — Systemic disturbances, such as "catching 
cold," arthritis, the eruptive specific fevers, syphilis, and tuberculosis, 
play an important role in the causation of catarrhal inflammations of the 
larynx. "Catching cold" is a complex process difficult to explain, but in 
general it maybe said to include a lack of balance of the vasomotor 
nerves whereby the capillary vessels are erratically controlled. Increased 
vascularity, or congestion, is thus a common disturbance. According to 
Woakes and J. A. Stucky, the phenomena of "catching cold" are due to 
digestive disturbances and the final results thereof, e. g., toxic products 
29 



450 DISEASES OF THE LARYNX 

in the circulation, which irritate the vasomotor nerves, thus establishing 
a predisposition to " catching cold." Clinical observation seems to sup- 
port the above theory in that acute laryngitis quite often follows or 
accompanies digestive disorders. Arthritis also seems to have a causa- 
tive relation to laryngitis, and, inasmuch as it is an inflammatory dis- 
ease of infectious origin, it is easy to appreciate the fact that certain 
toxins are in the circulation and affect the tonicity of the vasomotor 
system, very much as in acute coryza, or ''catching cold." The toxins of 
syphilis and tuberculosis likewise irritate and disturb the vocal apparatus. 
In addition, the pathological lesions are often localized in the larynx, and 
are specific in character. The exanthematous or eruptive fevers are 
often accompanied or followed by laryngitis. The specific microorgan- 
isms peculiar to these diseases are especially profuse in the upper respira- 
tory tract; indeed, they probably gain entrance to the system through 
the mucosa of the nose and throat when the resistance is lowered, espe- 
cially through the tonsils and adenoids; hence, the mucosa of the larynx 
is subjcted to the direct irritation from their presence, as well as to the 
toxins in the blood. 

2. Pre-existing Diseases. — Pre-existing diseases of the upper respiratory- 
tract are important predisposing etiological factors in laryngitis. This is 
especially true in reference to diseases of the sinuses, nasal stenosis, and 
infectious inflammations of the tonsils. It may be stated as an axiom 
that inflammatory processes in one part of the upper respiratory tract tend 
to extend to contiguous parts. This is in part explained by the extension 
by continuity of tissue, and in part by the simultaneous exposure of the 
various structures to microbic and toxic irritation. The most vulnerable 
area is first affected, the contiguous parts becoming involved later. The 
tendency is for the inflammatory process to extend downward rather than 
upward, probably because the flow of the lymph streams is in that direc- 
tion. It is true, however, that there is a marked hesitancy in the down- 
ward extension from the nose to the larynx. This is explained by the 
difference in the character of the epithelium covering the mesopharynx. 
Nearly the whole of the mucosa of the upper respiratory tract, except 
the mesopharynx, is covered with ciliated columnar epithelium, whereas 
the mesopharynx is covered with squamous epithelium. Inflammatory 
processes do not readily extend from one kind of tissue to another, hence 
the hesitancy. If, however, the nasal inflammation is severe and pro- 
longed, or often repeated, the inflammation finally reaches the larynx. 
Indeed, the "dropping" into the hypopharynx often leads to catarrhal 
inflammation of the larynx by lowering the resistance of the laryngeal 
mucosa, which subsequently becomes infected. In sphenoidal and 
posterior ethmoidal sinuitis, the secretion and the exudate are discharged 
into the epipharynx and drop or trickle down the walls of the meso- 
pharynx to the upper surface of the larynx, thus irritating its mucosa. 
The mucous membrane of the larynx becomes lowered in resistance, and 
infection and inflammation follow. In obstructive deflections of the 
septum the respiratory functions of the nose, namely moistening, warm- 
ing, and filtering the air, are impaired. The pharyngeal and the laryn- 



ACUTE CATARRHAL LARYNGITIS 451 

geal mucous membranes are, therefore, subjected to air that is irritating to 
them. This in time causes lowered resistance, infection, and laryngitis. 

We may say, then, in a general way, that diseases of the respiratory 
tract above the larynx often predispose to catarrhal inflammations of the 
larynx by (a) extension or continuity of tissue; (b) by contiguity of tissue; 
(c) by lymphatic communication; (d) by irritation and lowered resistance 
from secretions from the nose and accessory sinuses ; (e) by simultaneous 
exposure of the entire upper respiratory tract to microbic infection; 
and (/) by the irritation from the toxins evolved by the bacteria in the 
nose, the accessory sinuses, the epipharynx, and the tonsils. The chief 
barrier to the downivard inflammatory extension is in the squamous 
epithelium of the mesopharynx. 

3. Hygienic Conditions and Environment. — Under hygienic conditions 
and environment as causative agents in catarrhal laryngitis are included 
(a) the inhalation of noxious gases; (b) poor ventilation; (c) undue 
exposure of feet and body; (d) improper bathing; and (e) the abuse of 
the voice. 

The inhalation of noxious gases, as in chemical laboratories, factories, 
etc., may cause laryngitis by direct irritation, or it may lower the resist- 
ance of the tissues and predispose to infection. Poor ventilation likewise 
causes laryngitis, though not by direct irritation. In the latter instance 
the vital energy is lowered by breathing impure air. Then, too, the 
oxygen in the air is diminished in quantity. The vitiated atmosphere 
irritates the endothelial lining of the air vesicles, and thereby causes 
changes which interfere with the absorption of oxygen into the blood 
and the expulsion of carbonic acid gas from the blood. These factors 
combine to deprive the patient of the normal amount of oxygen, and lead 
to an overaccumulation of carbonic acid gas. The processes of metab- 
olism are thus deranged, and toxemia results. The vital energies are 
lowered, and the patient is in prime condition to be affected by bacterial 
infection and inflammation. Undue exposure of the body, especially 
the feet, is a prolific exciting cause of laryngeal inflammation. The large 
vessels of the feet give off large quantities of heat when the soles are in- 
sufficiently protected from the cold ground. When this occurs there is a 
shock to the terminal vascular system, which causes a lack of balance of 
the physiological functions of the more delicate structures of the body. 
The larynx in some cases is the vulnerable point, and reacts in the form 
of a catarrhal laryngitis. The question of clothing is discussed more 
fully under the etiology of the nasal inflammations. Suffice it to say, 
tnerefore, that there is danger in an excessive amount of clothing, as well 
as in too little. One accustomed to living in an open, poorly constructed 
residence, and changing to a well-built city residence, which is overheated 
and poorly ventilated, is especially subject to catarrhal inflammations of 
the upper air passages. 

Bathing, when judiciously practised, is a healthful and invigorating 
procedure. When, on the contrary, it is injudiciously practised, it may 
cause considerable mischief to the upper respiratory tract. What is good 
practice for one may be bad for another. Hard-and-fast rules cannot be 



452 



DISEASES OF THE LARYNX 



laid down. For some a cold plunge or shower bath after a warm bath 
is invigorating, while for others it throws them into a mild state of shock 
from which they do not quickly react. A Turkish bath is often a harmful 
procedure unless the bather remains for some hours in rooms of gradually 
diminished temperature. Hyperemia of the superficial vessels is induced, 
and if the bather goes out into the open air before the circulatory balance 
is restored, he is likely to " catch cold." The abuse of the vocal apparatus 
in singing and speaking disturbs the circulatory poise, and by mechanical 
irritation excites inflammation of the cords and the mucous membrane. 

4. Traumatism. — Chemical or mechanical injury of the cords or 
adjacent mucous membrane may cause laryngitis. 

5. Age. — Laryngitis is more common in young adults. 

6. Climate. — Laryngitis is more common in the temperate zones, espe- 
cially during the early spring and late autumn months, as the weather 
conditions are very changeable. 

7. Idiopathic. — In some cases the cause is unknown. In such cases 
it is probable that certain cachexia are present though not well defined. 
The iodides are usually beneficial in these cases. 

Pathology. — The histological changes in acute catarrhal laryngitis 
are the same as in inflammations of the mucosa of other portions of the 
upper respiratory tract. The peripheral vessels are congested and the 
tissues are infiltrated with round cells and leukocytes. If the inflamma- 
tion runs a short course the infiltration disappears, leaving little or no 
trace of its occurrence. Should the inflammation be phlegmonous, the 
tissues become edematous and the surface epithelium eroded in patches. 
The secretions at first thin and scanty, later become heavier and more 
profuse. In severe cases they may become purulent and streaked with 
blood from the superficial follicular ulcers. The pathology of laryngitis 
secondary to the exanthematous fevers does not differ from ordinary 
laryngitis except as to the microorganisms causing the disease and the 
greater tendency to phlegmonous inflammation. The greatest swelling 
in laryngitis is naturally in the most lax parts, namely, in the ventricles, 
though the true cords are sometimes red and swollen like sausages. In 
children the swelling is sometimes below the cords, and is a source of 
extreme danger. 

Symptoms. — Objective Symptoms. — The objective symptoms are a 
change in the appearance of the cords, the mucosa, the secretions, the 
exudate, and the presence of pathogenic bacteria. With the laryngeal 
mirror and reflected light an inverted image of the larynx is shown. The 
mucosa is red and more or less swollen from hyperemia and infiltration, 
or edema, according to the virulency of the inflammatory process. The 
cords are pinkish red, or even as red as the mucosa. Sometimes ecchy- 
motic spots of extravasated blood may be seen on their upper surfaces, 
or free borders. The secretions at first thin and scanty later become 
thick, semitranslucent, or opaque, according to the amount of lympho- 
cytes thrown out. They have a tendency to accumulate at the anterior 
commissure and to some extent along the cords. They appear as opaque 
plugs rather than as thin, diffused, glairy masses. 



ACUTE CATARRHAL LARYNGITIS 453 

When follicular ulcers are present, the denuded areas appear as slightly 
roughened red spots, or, if covered with secretions, as whitish opaque 
ones. In some cases there is a cloudy swelling of the epithelium in iso- 
lated areas. These areas are the beginnings of ulcerations. They appear 
as slightly elevated patches, with a grayish semitranslucent covering. 
Hemorrhages may occur at the commissure of the cords, or on the ven- 
tricular bands. At first the site of the hemorrhage is red, later almost 
black. When the inflammation is severe the venous flow may be blocked 
so that the parts are edematous. This condition is sometimes termed 
hydrops laryngis. The temperature varies from a slight elevation to one 
of several degrees, according to the severity of the inflammation and 
the virulency of the microorganisms contributing to the phenomena. 
The paralysis or paresis of the intrinsic muscles of the larynx, which 
sometimes occurs, may be due to a neurosis, though it is more often 
due to a mechanical interference by infiltration and degeneration of the 
muscles and the tissues immediately surrounding the nerve endings. 

Subjective Symptoms. — The subjective symptoms are changes in voice 
and respiration, and pain and cough. The voice may be hoarse in any 
degree, or aphonia may be present. The hoarseness is due to the swell- 
ing and infiltration of the cords and adjacent mucous membrane, and 
to the paresis or paralysis of the muscles. The respiratory effort may 
be slightly labored, on account of the diminished lumen of the chink 
of the glottis, or to the paresis or paralysis of the abductor muscles. 

In cases complicated by excessive edema, the respiration may be 
labored because of the edematous swelling. The respiration is shallow 
because the cough is excited by deep breathing. The character of the 
cough depends largely upon the individual, though it bears some rela- 
tionship to the stage and intensity of the disease. In the early stage it 
is usually soft and husky, whereas later it is more heavy and harsh. 
In those cases in which there is extensive infiltration and edema it is 
spasmodic, hoarse, and wheezy, but with little tonal quality. If the 
inflammation is limited to the interarytenoid space, hoarseness may be 
absent. 

Prognosis. — The prognosis depends somewhat upon the primary 
cause, that is, whether the laryngitis is due to a chronic constitutional 
disease, like syphilis, or to a simple exposure which causes temporary 
lowered resistance of the tissues. If due to the former, the prognosis as 
to the voice is bad. If to the latter, it is good. If the attack is primary, 
it is good. If it is one of a series of acute attacks, the chances are in favor 
of its recurrence, as the etiology is evidently a fixed factor. Again, the 
prognosis depends largely upon the character of treatment administered. 
It is obvious that if the cause is a nasal obstruction from septal malfor- 
mation, the prognosis will depend upon the treatment instituted. If due 
to nasal disease, and sprays, lozenges, and only medicated nebulae are 
used, the prognosis is bad. If the nasal disease is corrected by suitable 
treatment or an operation, the prognosis is good. Finally, and perhaps 
of more importance than all other considerations, the prognosis depends 
upon whether complete rest of the vocal apparatus is observed. If this 



454 DISEASES OF THE LARYNX 

is done for from three to ten days, simple catarrhal inflammation will 
subside, leaving the voice clear. 

Treatment. — The successful treatment of the immediate symptoms 
consists largely in giving the voice complete rest. Without this all other 
methods are usually futile and the inflammation rims its full course. 
The patient should be confined to his room, the temperature of which 
should be maintained at from 67° to 70° F. The atmosphere should be 
surcharged with steam from boiling water to which turpentine and 
creosote have been added. The bowels should be kept open with calo- 
mel and salines. The feet should be placed in a hot mustard bath, after 
which hot lemonade should be administered. The patient should then 
be wrapped in a woollen blanket and put to bed. Still further relaxation 
may be induced by the administration of effervescing tablets of pilocar- 
pine, y-j^Q- of a grain. One tablet should be given every hour until three 
or four are taken. The inhalation of steam impregnated with the com- 
pound tincture of benzoin, one teaspoonful to the pint of boiling water, 
from the spout of a croup kettle, affords relief, and should be used every 
two to three hours. Kyle recommends the following prescription : 

I^,— Acidi nitrici . Uliij (0.18) 

Tr. opii deodorati Hliij (0.18) 

Cocaine plienati gr. ^ (0.006)— M. 

Sig. — Give every hour until three or four doses are taken. 

The application of an ice-bag to the neck exerts a favorable influence 
in the phlegmonous variety, though it should not be applied longer than 
a few minutes at a time. A compress of cold water applied over the 
larynx beneath a flannel bandage also relieves the laryngitis, as it induces 
hyperemia and leukocytosis just as heat does. It is an open question 
as to whether the relief is due to the compress per se or to the constric- 
tion of the bandage, according to Bier's principle. The constriction 
also increases the local leukocytosis and thus frees the inflamed tissues of 
the infectious agents and dead tissue cells. Whether the good results are 
due to the water compress or to the constriction, the effects are favorable. 
An oily spray of menthol, 1 to 2 grs. to the ounce, is a pleasant appli- 
cation, affording temporary relief. Its frequent use, however, irritates 
the mucous membrane, hence it should not be used more often than 
twice a day. 

In severe cases in which there is considerable obstruction to the breath- 
ing, it may be necessary to puncture the swollen laryngeal mucosa with 
a laryngeal knife (Fig. 301). The serous fluid in the edematous mem- 
brane is thus let out without serious damage to the parts, and in addition 
the reaction of inflammation is promoted and the bacteria more rapidly 
destroyed. In extreme cases it may become necessary to intubate or 
to perform tracheotomy. (See Intubation and Tracheotomy.) 

In infants the danger in acute laryngitis is much greater than in adults, 
on account of the relatively smaller and more easily occluded chink 
of the glottis. Then, too, the mucosa is much more richly supplied 
with lymphatics and bloodvessels and is more loosely attached to the 



ACUTE LARYNGITIS IN CHILDREN 455 

deeper structures. For these reasons the mucosa is more likely to be- 
come swollen or edematous and cause suffocation. A fatal issue is 
possible. 

For the relief of the cough, codeine sulphate, gr. -^ to J, may be 
administered every three hours until relief is afforded. 

After the second week it may be advisable to touch the inflamed 
cords with the solid stick of nitrate of silver. This should be done but 
once. In the milder cases the larynx may be painted with a 2 to 4 per 
cent, solution of the nitrate of silver. 

Fig. 301 

h e 



Laryngeal lancet. 

The principles of treatment are: (a) Absolute rest of the voice, the 
patient remaining in a warm room containing steam vapor, (b) Free 
purgation to promote the elimination of the toxins and ferments, and 
(c) relaxation of the peripheral vessels of the body by the administration 
of pilocarpine and hot drinks, (d) Diaphoresis, aided by wrapping in 
warm blankets, (e) The relief of cough by the use of codeine or other 
sedatives. (/) Scarification, intubation, or tracheotomy in threatened 
suffocation, (g) Caustic and astringent applications in the late stage. 



ACUTE LARYNGITIS IN CHILDREN 

Synonyms. — Pseudocroup; false croup; Miller's asthma; laryngitis 
stridulosa. 

In children, acute laryngitis is often characterized by a spasmodic, 
croupy, or barking cough and suffocative fits. The subjective symp- 
toms are quite like those of tracheal diphtheria, hence the name 
pseudocroup. Histologically it is a true catarrhal process. 

Etiology. — The etiology of catarrhal laryngitis in children is in general 
like that of catarrhal laryngitis in adults, though many of the exciting 
causes may be absent, on account of the different habits of the child 
or infant. The special etiology in children consists of the presence of 
adenoids and the epipharyngitis which accompanies them, and in the 
different anatomical construction of the larynx. In children the chink of 
the glottis is both relatively and absolutely smaller, the lymphatic and 
vascular structures are more abundant, and the mucosa is more loosely 
attached to the underlying tissues. All these factors predispose the 
larynx of the child to attacks oi laryngitis; they also render the disease a 



456 DISEASES OF THE LARYNX 

much more serious one on account of the tendency to suffocation. To the 
foregoing facts should be added the greater susceptibility of children on 
account of the unstable condition of the nervous system and glandular 
tissues. A moderate amount of swelling of the mucosa, either above or 
below the true cords, to which is added an irritation of the terminal motor 
nerve filaments, is often sufficient to bring on severe and alarming fits 
of dyspnea and suffocation, even to the point of death. 

The disease in children may be divided into two varieties, namely, 
(a) acute supraglottic laryngitis, and (6) subglottic laryngitis, or Miller's 
asthma. 

The symptoms of acute supraglottic laryngitis more nearly resemble 
those of the adult type, though in many cases the spasmodic suffocative 
fits are present on account of the extreme swelling and edema of the 
mucosa and the paresis of the abductor muscles. 

The subglottic variety is more dangerous because the swollen mucous 
membrane is confined at its circumference by the cartilaginous rings 
of the trachea. The swelling must, perforce, encroach upon the lumen 
of the trachea, and close the breathway. 

Symptoms. — The objective symptoms are about the same as in the 
adult. (See Acute Catarrhal Laryngitis.) The subjective symptoms are 
somewhat different on account of the greater swelling and the smaller 
lumen of the chink of the glottis. The prodromal symptoms are those 
of cold, the respiration becoming embarrassed toward evening. A dry 
cough develops before bedtime, but is not severe enough to prevent 
sleep. Toward midnight the child is suddenly seized with a laryngeal 
spasm, and breathing becomes difficult. The cough is loud and harsh. 
Inspiration is difficult, and is accompanied by stridor. The child becomes 
cyanotic, and death is imminent. After a few minutes, the symptoms 
disappear and the child falls asleep. The following night, and perhaps 
for two nights, the attack returns with diminishing severity, until after 
a few days all signs of the disease disappear. In these cases there is a 
true spasm of the muscles of the larynx, probably due to the natural 
hypersensitiveness of the nervous system in infants and growing children. 
In the subglottic variety the swollen mucosa beneath the true cords may 
be seen through the chink of the glottis as beefy-red bands. These 
cases closely resemble tracheal diphtheria in their subjective symptoms, 
though an inspection of the larynx and a microscopic examination of 
the secretion and exudate will clear the diagnosis. 

Diagnosis. — Acute laryngitis in children should be differentiated from 
diphtheria, pseudomembranous croup, laryngismus stridulus, foreign 
bodies, and perichondritis. 

Diphtheria is characterized objectively by a membranous deposit, 
which may be seen upon laryngoscopic examination. It may be either 
on the laryngeal mucosa or in the trachea, or both. Cultures show the 
diphtheria bacilli. In acute laryngitis there is an absence of the false 
membrane and the bacilli, while the mucosa is greatly swollen and red- 
dened. If it is of the subglottic variety, the swollen red mucous mem- 
brane may appear as round, reddened cords, parallel with and below 



ACUTE LARYNGITIS IN CHILDREN 457 

the true cords. The temperature is usually higher in acute laryngitis 
in children than in true diphtheria, while the prostration is not so great. 

Pseudomembranous croup has a sudden onset, while acute laryngitis 
begins with the symptoms of a cold. In pseudomembranous croup the 
suffocative symptoms make steady progress with little or no remission. 
The laryngoscopic image in pseudomembranous croup shows the pres- 
ence of the membrane, whereas in acute laryngitis the mucosa is red 
and swollen. The Klebs-Loeffler bacilli are absent in both diseases. 
The systemic disturbance is less marked and not so severe. There are 
no nocturnal exacerbations, as there are in acute laryngitis with the 
laryngismus stridulus phenomena superimposed. 

Foreign bodies in the larynx are differentiated by the history of the 
accident, the sudden onset of the suffocative symptoms with no pro- 
dromal history, and the image of the foreign body in the larynx. 

Perichondritis of the cricoid cartilage is characterized by irregular 
nodules in this region and the chronicity of the case. It is usually 
associated with a tuberculous process in the lungs. 

Prognosis. — The prognosis of acute laryngitis in children is favorable 
in most cases, though a fatal termination is possible, especially in the 
subglottic variety. The disease runs its course in from six to twelve 
days. 

Treatment. — Prophylactic measures should be instituted in those 
cases in which there is a history of recurrent attacks. A child subject 
to laryngitis with pulmonary complications, as bronchitis, should have 
the tone of the system built up by daily cold sponge baths, followed by 
brisk rubbing with a towel until the skin glows. During the summer 
he should be kept in the open air as much as possible. At night the 
room should be well ventilated. The food should be nutritious, easily 
digested, and liberal in quantity. The clothing should be of linen mesh 
next to the skin all the year round. In the winter light woollen under- 
wear should be worn over the linen mesh. If there are adenoids or 
diseased tonsils, they should be removed. If suppurative rhinitis is 
present, it should receive appropriate treatment. All other ailments 
should be corrected as early as possible. In short, all disorders should 
receive attention and a healthful vigor be established as soon as possible. 
In this way laryngeal inflammation may be prevented. 

In the beginning of the acute attack, the bowels should be moved 
by the administration of broken doses of calomel, followed by a saline 
cathartic. During the acute stage the child should be confined in a room 
kept at a temperature of about 70°, and the atmosphere surcharged 
with steam. The feet should be placed in hot mustard water for fifteen 
minutes, after which the patient should be wrapped in a woollen blanket 
and put to bed, to promote diaphoresis. If there is much mucus in 
the throat and trachea, an emetic should be administered. If the secre- 
tions are scanty or tenacious, the inhalation of menthol vapor from a 
nebulizer, or from the crystals in boiling water, stimulates the secretions 
and gives marked relief. 

The external application of an ice-bag or a cold compress to the neck 



458 DISEASES OF THE LARYNX 

often affords relief. The ice-bag should be covered with woolen cloth 
and left in position for only a few minutes at a time. Counterirritation 
to the neck with iodine, camphorated oil, kerosene, etc., is used to relieve 
the swelling when it is great, and to promote the reaction of inflammation. 
(See Chapter VII.) 

In the later stage, paregoric, Dover's powder, codeine, etc., may be 
administered in small doses to relieve the cough. If the secretion is 
heavy and accumulates in the larynx and trachea, an emetic should 
be given to clear it away. 

Surgical interference may be necessary when the symptoms become 
alarming. If, upon laryngoscopic examination, the mucous membrane 
above the cords is found to be greatly swollen, it should be punctured 
with a laryngeal lancet (Fig. 301). Or if the cyanosis is marked and 
does not yield to other methods of treatment, intubation or tracheotomy 
should be performed to save the child's life. (See Intubation and Trache- 
otomy.) These extreme measures are rarely necessary, but it is well to 
recognize that in children this disease is sometimes attended with death 
unless the breathing is maintained by medicinal, hygienic, or surgical 
interference. 

ACUTE PHLEGMONOUS LARYNGITIS 

Definition. — Acute phlegmonous laryngitis is a catarrhal inflamma- 
tion of the laryngeal mucosa, to which is added an edematous effusion 
which runs an inflammatory course, for example, serous, seropurulent, 
and purulent stages. The mucous membrane becomes undermined with 
purulent secretion. 

Etiology. — The causes of this variety of laryngitis are about the same 
as in acute catarrhal laryngitis, except that the infection is more virulent. 
The disease is common among hospital attendants, on account of their 
exposure to erysipelas and other infectious diseases. It is rarely primary, 
but is usually secondary to some other infectious disease. It occurs 
most frequently between the twentieth and the fortieth years of life. 

Pathology.— The pathology is the same as in inflammatory edema 
of mucous membranes elsewhere in the body. The mucous and sub- 
mucous tissue are infiltrated with round cells, and there is an effusion 
of serum and pus corpuscles. On account of the loose texture of the 
mucous membrane in the aryepiglottic region, the ventricular bands, and 
the subglottic region, there is great swelling and respiratory obstruction, 
as in acute laryngitis of children. There is at first a vascular engorge- 
ment, followed by a serous effusion. Later, the effusion takes on a 
seropurulent and finally a purulent character. General sepsis may 
follow, and prove to be a serious complication. 

Symptoms. — The symptoms during the first twenty-four hours are 
about the same as in the acute catarrhal variety. A chill and elevation 
of temperature are often the initial ones. The symptoms gradually 
grow worse, and dyspnea often occurs within the first twenty-four hours. 
Pain and soreness are usually complained of. Cough may or may not 
be present. 



MEMBRANOUS LARYNGITIS 459 

Objectively, the laryngoscopic mirror shows the mucous membrane 
to be red, tense, and glassy, with three rounded, swollen masses above 
the chink of the glottis. If the subglottic region is involved, the swollen 
membrane may be seen projecting from below the true cords. 

Prognosis. — The prognosis is grave on account of the rapid develop- 
ment and the septic infection. If, however, the dyspnea persists longer 
than thirty-six hours without severe sepsis or other untoward complica- 
tion, the case will probably end in spontaneous resolution. The cases 
should be closely watched during the first thirty-six hours. 

Treatment. — The treatment consists in local depletion with ice-bags, 
followed by the use of leeches and scarification. The ice-bag should be 
applied for forty minutes, after which three or four leeches, two on either 
side, should be applied to the skin over the larynx. The cold reduces 
the swelling and thus establishes a more rapid flow of blood through the 
inflamed tissues, and the leeches bring about an increased leukocytosis. 
The cellular resistance is increased by the greater amount of blood 
flowing through the tissues. The various reactions produced by the cold 
and leeches establish ideal conditions for the destruction of the infec- 
tious microorganisms. The administration of calomel and salines pro- 
mote the elimination of the toxins. The atmosphere of the room should 
be kept surcharged with steam. If scarification is resorted to, the laryn- 
geal lancet (Fig. 301) should be used by the aid of the laryngeal mirror 
and reflected light, or by direct laryngoscopy. The swollen mucous 
membrane should be repeatedly punctured rather than scarified, as the 
damage to the parts is less and the relief is equally great. The chief 
benefit of scarification is in the increased leukocytosis excited by it. 
It may be necessary to resort to tracheotomy if suffocation becomes 
imminent. If sepsis is a severe complication, the administration of 
alcoholic beverages and strychnine are indicated to support the system. 

MEMBRANOUS LARYNGITIS 

Synonyms. — Croup; croupous laryngitis; hautige braune ; diphtheritic 
laryngitis; pseudomembranous croup; idiopathic membranous croup. 

Definition. — Membranous laryngitis is characterized by an inflamma- 
tion of the larynx, attended with the formation of a false membrane of 
non-diphtheritic origin. Opinions differ as to the unity or duality of this 
disease and true diphtheria. The evidence, however, seems to show 
that they are two diseases, the latter being due to an infection from the 
Klebs-Loeffler bacillus, while the former (croup) is due to an infection 
from other microorganisms, usually the cocci, or to a caustic irritant. 
When due to the latter, the membrane is not of microbic origin, though it 
may become infected secondarily. Under the microscope it presents the 
same appearance as that due to cocci. 

Etiology. — The causes of membranous laryngitis are microbic, chemi- 
cal, and mechanical irritants. Exposure to damp and cold and neuroses 
are predisposing causes in young children. The cases of microbic origin 
usually follow or attend scarlet fever, measles, smallpox, etc. Exposure 



460 DISEASES OF THE LARYNX 

to damp and cold seems to precipitate attacks by lowering the vital 
resistance, and thus establishing a suitable soil for the bacterial growth. 
It appears that chemical and mechanical irritants cause the mem- 
branous formation without bacterial influence, although this is not 
certain. Some children seem to have a predisposition to a membranous 
inflammation of the larynx, though in these cases I suspect that ade- 
noids and epipharyngitis may cause the susceptibility. It is essen- 
tially a disease of young childhood, occurring chiefly between the ages 
of two and eight. It is most prevalent in the winter season. 

Pathology. — The membrane is in two layers, a superficial or epithelial, 
and a deeper or fibrous layer. It is comparatively loosely attached to 
the mucous membrane, whereas in diphtheria it is firmly attached. 
The epithelial layer of the mucosa is rapidly proliferated, and enters into 
the composition of the pseudomembrane. The mucous membrane is 
hyperemic and red, and in places is denuded of its epithelium. The 
bacteria causing the inflammation are chiefly cocci, for example, pneu- 
mococcus, streptococcus, and staphylococcus, though other bacteria, 
as the spirillum and the Bacillus pyocyaneus, are found and probably 
contribute to the etiology. The membrane is not grayish white, as it 
usually is in diphtheria, but is yellowish and of a soft, friable consistency. 
It is more easily removed, and does not leave an ulcerated or bleeding 
surface, as in diphtheria. 

Symptoms. — The laryngoscope shows a free fauces, a coated tongue, 
and hyperemia of the fauces and the larynx. The membranous forma- 
tion appears on the aryepiglottic folds, on the ventricles, and occasionally 
on the vocal cords. It is usually primary in the larynx, though it may 
originate in the fauces and pharynx, and spread to the larynx. The 
laryngoscopic image, therefore, shows a yellowish, friable membrane in 
one or more of these regions. The temperature rapidly rises to 102° 
or 103°. 

The onset of the disease may be the same as in acute catarrhal laryn- 
gitis, but in the course of an hour or two a loud, brassy cough develops, 
which steadily increases until toward midnight, when it reaches its 
climax. There is loss of appetite, and the patient complains of thirst. 
The pulse is full and the skin is hot and dry. Deglutition becomes 
painful. The cough, at first infrequent, becomes more and more fre- 
quent, and is finally followed by laryngeal spasm. Great dyspnea then 
comes on, and the child, in his endeavors to cough out the obstructing 
membrane, clutches at his throat and tosses about in his bed. These 
symptoms increase in severity as the membrane is formed in the larynx, 
until the voice is aphonic (silent croup) and the inspiration through the 
narrowed glottis gives rise to a peculiar crowing sound. The next morn- 
ing the symptoms are lessened in severity, only to be increased again in 
the evening. Sometimes the climax is delayed until the third night. The 
disease is progressive, whereas in laryngitis the obstructive symptoms 
are spasmodic and are not steadily progressive. In case of marked 
glottic obstruction the inspiratory and expiratory dyspnea and asphyxia 
may necessitate intubation or tracheotomy. 



MEMBRANOUS LARYNGITIS 461 

If the dyspnea continues, the pulse becomes weak, the temperature 
falls, and the general strength rapidly ebbs away on account of the 
diminished oxygenation of the blood and the increased amount of 
carbon dioxide in the blood. When the membrane is thick in the region 
of the soft palate there may be a regurgitation of fluid food through the 
nose. This is not due to paresis of the palatal muscles, as in true diph- 
theria, but is due to the mechanical interference of the false membrane 
with the action of the muscles. 

Laryngismus stridulus sometimes appears in the course of the disease, 
and is to be regarded as a neurotic phenomenon. 

Diagnosis. — Membranous croup resembles in some respects spas- 
modic laryngitis, diphtheria, laryngismus stridulus, and retropharyngeal 
abscess. 

In spasmodic laryngitis there is a catarrhal inflammation with spasms 
of the laryngeal muscles, which cause suffocative symptoms. They 
disappear, however, in a few minutes and the child rests comfortably. In 
membranous croup the suffocative symptoms come on gradually and 
disappear as gradually. 

In diphtheria the temperature does not rise so high or so rapidly. 
The chief diagnostic points, however, are the culture of the Klebs-Loeffler 
bacilli and the ashen-gray and firmly adherent pseudomembrane. After 
its removal the mucous membrane is ulcerated and bleeding, whereas in 
membranous croup it is smooth and does not bleed. 

Laryngismus stridulus is a neurosis and not an inflammatory disease, 
hence the laryngoscopic examination shows the absence of inflammation. 
Then, too, there is a history of a healthy child who suddenly has a fit of 
suffocation. In membranous croup there is a history of inflammation 
and progressive dyspnea. 

Retropharyngeal abscess may simulate membranous laryngitis in its 
suffocative symptoms; otherwise there is little similarity. An examina- 
tion of the throat reveals a fluctuating tumor on the posterior wall of 
the hypopharynx, whereas in membranous laryngitis the tumefaction 
is within the laryngeal zone. 

Prognosis. — The prognosis is grave. Some author's report a mortality 
of from 50 to 60 per cent, of the cases, while other report as low as 10 per 
cent. This discrepancy in the reported death rate is probably due to the 
difference in the diagnosis. Those who figure the death rate at 50 to 60 
per cent, probably include cases of true diphtheria. The prognosis is 
grave in inverse ratio to the age of the patients. The younger the patient 
the more serious the prognosis. In adults the danger is greatly diminished 
as the lumen of the larynx is relatively and actually greater, and the 
mucous membrane is more firmly attached. 

Complications. — Membranous laryngitis may become complicated 
with rapid edema of the bronchial mucous membrane or with cardiac 
infection. In either event the case becomes one of great gravity. 

Treatment. — The treatment consists in the administration of broken 
doses of calomel until free catharsis is produced, and in the inhalation 
of steam vapor charged with lime and turpentine. The child should be 



462 DISEASES OF THE LARYNX 

put into a tent-bed and a pound of lime should be placed in a bucket of 
water, to which has been added a tablespoonful of the spirit of turpen- 
tine. The tent-bed is thus filled with the vapor, which is inhaled by 
the child. The lime and turpentine seem to aid in loosening and expel- 
ling the false membrane. The steam-tent seances should last about 
fifteen minutes, and should be repeated every four or five hours. The 
efficiency of the steam-tent baths is increased by the administration 
of ipecacuanha wine or powder, which is a non-depressing emetic. 

Calomel fumigations, as advocated by Corlin, have proved an efficient 
method of treatment. He recommends the administration of one or 
two grains of calomel before the fumigation begins. The patient should 
then be placed in a completely closed tent-bed. It requires about ten 
minutes to volatilize the calomel, and the patient should be exposed to 
the fumes in the closed tent for about fifteen minutes. It is recommended 
that fifteen grains be volatilized every two hours for two days and nights, 
after which the intervals should be prolonged to three hours on the third 
day, four hours on the fourth day, and three times daily thereafter as 
long as indicated. Pure calomel thus used does not produce ptyalism, 
though anemia may occur and should be combated by the administra- 
tion of iron. 

EDEMA OF THE LARYNX 

Synonym. — Edema glottidis. 

Edema of the larynx is an inflammatory process attended with an 
edematous infiltration of the loose submucous tissue of the larynx, which 
is usually due to a more serious general disease of the heart, kidneys, 
or the liver, though it may be caused by local conditions. 

Etiology. — The local causes are mainly traumatic from the injudi- 
cious use of caustics, laryngeal injections of creosote in tuberculous in- 
flammations, operations, foreign bodies in the supraglottic region of the 
larynx, the swallowing of hot liquids and the inhalation of hot steam, or 
the inspiration of alcoholic or other irritating liquids into -the larynx. 
The prolonged or violent use of the voice, as in shouting, may bring on 
edema of the larynx. Local diseases of the larynx, as tuberculosis, 
syphilis, abscesses, neoplasms, perichondritis, and peritonsillitis, may 
also cause it. Abscess of the larynx may be accompanied by a non- 
inflammatory edema. 

The constitutional causes of simple edema of the larynx are Bright's 
disease, diabetes, valvular lesions of the heart, sclerosis of the liver, 
and Ludwig's angina. In the latter disease there is a neurotic paresis 
of the bloodvessels of the neck, which causes engorgement and edema. 
Certain drugs, as the iodide of potassium and the fumes of ammonia 
and bromine, may cause it. 

Pathology. — There is an effusion of clear serum into the laryngeal 
submucous tissue, producing swelling of the aryepiglottic folds and of 
the anterior and superior parts of the epiglottis. Sometimes the loose 
subglottic tissue becomes edematous. In associated ulcerative processes 
the serous infiltration may become seropurulent. 



ABSCESS OF THE LARYNX 463 

Symptoms. — The onset is sudden and is characterized by the loss 
of the voice and rapidly increasing dyspnea. In severe cases a fatal issue 
mav occur in from two to three hours by asphyxiation. There is little 
or no pain or cough. The laryngoscopic image shows the mucosa in 
the region of the aryepiglottic folds, the anterior and upper surface of 
the epiglottis, and sometimes the subglottic region to be tumefied. The 
surface of the mucous membrane is of a pale gray color, in marked con- 
trast to the tumefaction in phlegmonous or inflammatory edema of the 
larynx, in which it is red. 

Prognosis. — The prognosis is grave on account of the sudden develop- 
ment of the edema, and the serious nature of the constitutional disease 
back of it. If it is due to an extraneous irritation, the danger is less, 
and the chance of recurrence is less. 

Treatment. — If the disease is secondary to a serious constitutional 
disorder, this should, of course, receive appropriate treatment. For the 
immediate relief of the symptoms, cracked ice should be dissolved in 
the mouth, and the patient should be assured by the attending physician 
that the dyspnea will disappear, as the sense of impending death only 
aggravates the distress. Astringent applications of cocaine and adrenalin 
should be made. Diaphoresis and catharsis should be induced by the 
administration of Dover's powder, hot lemonade, etc., followed by a 
twelve-ounce bottle of the citrate of magnesia. In addition to the above, 
it may be necessary to puncture the edematous tissue with the laryn- 
geal lancet (Fig. 301). If suffocation is imminent, the patient should 
be tracheotomized (see Tracheotomy), to prevent a fatal issue. The 
surgeon should not hesitate to perform tracheotomy on a deeply cyanotic 
case because he does not have with him the instruments usually used 
for this purpose. A pocket knife, or a paring knife from the kitchen, 
may be quickly sterilized and used to open the trachea. A needle and 
thread may be used to retract the parts until a tracheotomy tube is 
secured. In the meantime, the patient's life has been saved, whereas 
to have waited for suitable instruments would have jeopardized his life. 



ABSCESS OF THE LARYNX 

Etiology. — Abscess of the larynx is usually a complication of tuber- 
culous perichondritis. Perichondritis of the laryngeal cartilages is 
attended with ulceration of the mucous membrane. Infectious bacteria 
gain entrance beneath the perichondrium and cause the formation of 
pus. The accumulated pus causes a rounded tumor-like mass. This 
is a laryngeal abscess. It has also been known to follow erysipelas of 
the larynx, and it may be of traumatic origin. 

Symptoms. — The abscess swelling encroaches upon the glottis, hence 
there are loss of voice and intense suffocative symptoms. It is an infec- 
tious inflammatory process, and causes fibrile phenomena. There is 
retention and pressure, hence pain in the larynx. The laryngoscopic 
image shows a greatly swollen and reddened mucous membrane at the 



464 DISEASES OF THE LARYNX 

site of the abscess. Upon puncturing it with the laryngeal lancet there 
is a free flow of pus. 

Treatment. — It is obvious that there is but one method of treatment, 
namely, the evacuation of the pus with a laryngeal lancet (Fig. 301). 
This may be done under cocaine anesthesia with the patient in the sitting 

Fig. 302 




Sajous' laryngeal forceps applicator. 

posture. The anesthesia is induced with a 10 to 20 per cent, solution 
of cocaine applied repeatedly with Sajous' forceps (Fig. 302). The 
curved laryngeal lancet should then be used with the aid of reflected 
light and the laryngoscopic mirror, or by direct laryngoscopy and the 
tumor-like mass freely incised. The relief is immediate. If suffocation 
threatens, tracheotomy may be necessary. (See Tracheotomy.) 



CHRONIC LARYNGITIS 

Definition. — Chronic inflammation of the mucous membrane of the 
larynx includes the glandular, vascular, and connective-tissue layers. 
It is usually secondary to acute attacks, or to inflammation in the nose, 
epipharynx, and tonsils, though it occasionally seems to occur as a 
primary affection. 

The following classification meets both the clinical and the pathological 
requirements : 

1. Chronic hypertrophic laryngitis. 

(a) Diffused hypertrophic laryngitis, sometimes called chronic 

hyperemic laryngitis. 

(b) Discrete or localized hypertrophy of the mucous membrane, 

either supraglottic or subglottic. 

(c) Chorditis nodosa, or trachoma of the vocal cords. 

2. Atrophic laryngitis. 

3. Hemorrhagic laryngitis. 

Chronic Hypertrophic Laryngitis.— (a) Chronic Diffused Laryngitis. 
—Each of the three varieties of chronic hypertrophic laryngitis presents 
a distinct clinical and pathological picture, hence they will be described 
separately. 

Synonym. — It is sometimes called hyperemic laryngitis. 

It is characterized by a diffused infiltration throughout the laryngeal 



CHRONIC LARYNGITIS 465 

mucosa, no one part being affected more than another. As it is due to 
irritations of a general character, rather than to those directed to one 
part, it is easy to understand the diffusion of the hypertrophy and 
hyperemia. 

Etiology. — It is extremely doubtful if there is a primary chronic laryn- 
gitis, except from the improper use of the voice. It is always, or nearly 
always, secondary to a preceding disease of the nose, epipharynx, or 
the faucial tonsils. It is possible to conceive of a chronic laryngitis 
following the excessive use of tobacco or alcohol, or even following diges- 
tive disturbances. Clinically, however, it is rare to see cases in w T hich 
there is not an associated or a preceding disease higher up in the respira- 
tory tract. The diffused hypertrophic variety arises from obstructed 
nasal breathing and from the discharge of secretion from the sinuses 
into the pharynx. Other sources of irritation may also be present, 
but they are generally incidental and of secondary importance. 

The etiology may be classified under the following headings: 

1. Improper preparation of the inspired air on account of disease 
of the nose and sinuses. 

2. Hematogenous irritation of the larynx in mouth breathing, hepatic 
and digestive disorders. 

3. Passive hyperemia in cardiac disease, thoracic tumors, and enlarged 
glands. 

4. Smoking, inhalation of dust-laden air, excessive use of alcohol, 
and violent use of the voice. 

5. Climatic conditions. 

6. Age and sex. 

Mouth breathing, adenoids, deflections of the septum, tarbinal hyper- 
trophy, sinuitis, and polypi, also improper breathing by public speakers 
and singers, lead to a diffused irritation of the laryngeal mucous mem- 
brane. As the improperly prepared air and secretions pass over the 
whole laryngeal mucosa, there is a diffused hypertrophy. As the air 
in damp cold weather is more irritating than it is in warm and bright 
weather, it follows that the symptoms are aggravated during the winter 
and early spring months in the higher latitudes. This is especially true 
in the region of the Great Lakes and on the northern Atlantic coast 
of the United States. 

The breathing of improperly prepared air results in deficient oxygena- 
tion of the tissues and an excess of carbon dioxide in the blood. This 
in turn disturbs the metabolic processes, and still further loads the blood 
with deleterious material. This blood in circulating through the laryn- 
geal mucosa irritates all its parts, and causes a diffused hyperemia and 
hypertrophy. The excessive use of alcohol and tobacco similarly affects 
the larynx. Smoking does it by direct irritation, and indirectly through 
the blood. The ingestion of alcohol affects the larynx by direct irrita- 
tion of neighboring parts, and through the circulation, to say nothing of 
the digestive and metabolic disturbances thus aroused. The foregoing 
etiological factors predispose the larynx to acute attacks, and the chronic 
state is usually a sequel or a continuation of repeated acute inflammations. 
30 



466 



DISEASES OF THE LARYNX 



I am of the opinion that through disease and obstruction in the nose the 
laryngeal mucosa is kept in a state of irritability, and is made susceptible 
to chronic inflammation by the inspiration of the improperly prepared 
air and by the toxins in the blood. At the age of puberty, boys are 
subject to attacks of chronic laryngitis on account of the unstable condi- 
tion of the vasomotor nervous system, the rapid development of the 
larynx, and the consequent instability of the same. Any disease of the 
heart, wherein there is an interference with the return circulation, may 
cause huskiness of the voice and perhaps diffused hypertrophy of the 
mucous membrane. Thoracic tumors, or enlarged thoracic and cervical 
glands, also interfere with the return circulation, and lead to hypertrophic 
changes. Stonecutters, tobacconists, metalworkers, and workers with 
certain chemicals are often affected by chronic laryngitis from the inhala- 
tion of the contaminated air. Men are more often affected than women, 
for obvious reasons. The aged are more subject to it on account of 
the vascular and glandular changes accompanying senility. Indeed, 
many old people living in the northern part of the United States are 
more or less afflicted with chronic laryngitis. 

Pathology. — There is a diffused hypertrophy of the laryngeal mucous 
membrane, including the glandular and the connective tissue. The 
bloodvessels are but little affected excepting a few small arteries on the 
surface of the epiglottis and the vocal cords, where they may be enlarged. 

Symptoms. — The objective symptoms of diffused hypertrophic laryn- 
gitis, if carefully studied, are somewhat different from those of the other 
two varieties of hypertrophic laryngitis, and are as follows: 

Diffused hyperemia of the laryngeal mucous membrane, including 
that of the epiglottis, is usually present. It may be more marked in the 
ventricular pouches, on the epiglottis, the aryepiglottic folds, or on the 
vocal and the ventricular bands. Indeed, it often spreads from one 
part to another in the order given above, until in the later stages it is 
general. In singers and speakers the hyperemia is generally greater in, 
or is entirely limited to, the true cords. The color varies in different 
individuals, and, indeed, in the same case at different times. The cords 
may be the normal ivory white, or pinkish red, or they may be streaked 
with red, or they may be of a pale, mottled brown or slaty gray color. 
Enlarged bloodvessels are rarely seen, except upon the epiglottis and 
the vocal cords. 

The secretions are increased but little, indeed, in some cases they are 
apparently decreased. The image may present, therefore, either a moist 
or a dry membrane. The hyperemia is rarely demonstrable by laryngo- 
scopy examination. The mobility of the cords is usually unaffected, 
though in some cases there is a tardy action from the infiltration of the 
intrinsic muscles. 

The subjective symptoms have reference to the voice, the sense of 
accumulated secretions, and the ease with which the vocal apparatus 
becomes tired. The voice upon rising is often quite husky, or even 
aphonic. During the day it becomes nearly or entirely clear, unless it is 



CHRONIC LARYNGITIS 467 

used excessively. In this event it remains husky, and its use is attended 
with aching in the larynx. 

The diffused hyperemia and hypertrophy give rise to the sense of 
accumulated secretions and the desire to clear the throat. 

Diagnosis. — The diagnosis is based upon the hoarseness or aphonia, 
the diffused hyperemia in the later stage, the absence of discrete hyper- 
trophy, and the small amount of expectoration, except when complicated 
by bronchitis. 

Prognosis. — The prognosis in the early stage is good, but when the 
hyperemia has extended over the entire mucosa, it is not so favorable. 
If the laryngitis is due to the excessive use of alcohol or tobacco, or to 
an excessive or violent use of the voice, the excesses should be corrected. 
If it is due to nasal obstruction or to adenoids these conditions should 
be corrected. No matter what the cause, the prognosis as to the voice 
is bad if the hypertrophy is great. In these cases there may be an infil- 
tration of the thyro-arytenoidei interni muscles, thus giving rise to a 
sluggish action of the cords. 

Treatment. — From the foregoing description of the disease it is appar- 
ent that the treatment must be addressed to (a) the correction of the pre- 
existing disease of the nose and sinuses; (b) the removal of adenoids; 
(c) the discontinuance of the use of tobacco and alcohol; (d) the correc- 
tion of digestive and hepatic disorders; and (e) the avoidance of excessive 
use of the vocal organs. 

When the nose and accessory sinuses are the seat of a catarrhal or 
a suppurative inflammation, they should receive appropriate attention. 
Deflections of the septum, turbinal hypertrophies, sinuitis, polypi, etc., 
should be corrected or removed by surgical procedures. Adenoids, if 
present, even though they are somewhat reduced by atrophy in adults, 
should be removed, and the associated epipharyngitis treated with silver 
applications. The faucial tonsils when enlarged or diseased should be 
removed in their entirety. The use of tobacco and alcoholic beverages 
should be forbidden, as but little benefit can be expected while the larynx 
is subjected to their deleterious effects. Singers who practise improper 
placement of the voice should either be forbidden to sing, or be taught 
proper methods of voice placement. (See the Singing Voice.) Violent 
use of the voice, either in singing or speaking, should be avoided. 

The use of sprays, gargles, and oily nebulae by the patient are of little 
value. These remedies, at most, can do no more than thin the secre- 
tions and thus facilitate their expulsion. 

Local applications of a 2 to 10 per cent, solution of the nitrate of silver 
with Sajous' forceps should be made three times a week. The chloride 
of zinc in the same strength should be tried, although I have found 
nothing as efficacious as the nitrate of silver. Other preparations of 
silver in my hands have proved disappointing. In making applica- 
tions to the larynx the excess of fluid should be squeezed from the cotton 
to prevent it trickling between the cords, where it excites spasm of the 
laryngeal muscles. Should a spasm occur, instruct the patient to take 
a number of deep breaths in rapid succession, Sustained efforts of this 



468 DISEASES OF THE LARYNX 

sort quickly stop the spasms. Spasms of the larynx excited by an excess 
of silver solution may be so violent as to cause cyanosis and extreme 
apprehension on the part of the patient. 

Constitutional remedies, as saline cathartics, calomel, and the iodide 
of potash, should be given if syphilis is suspected. They are often of 
value in small doses when syphilis is not present, as the cathartics 
improve the elimination, while the iodide of potash stimulates the 
glands. 

The improvement following the correction of digestive and hepatic 
disorders is often very gratifying. To this end I advise the daily use 
of one of the bitter salines in small doses, and a five grain dose of the 
iodide of potash three times a day. Jn addition to these remedies, it may 
be necessary to use others, according to the needs of the case. If chronic 
bronchitis is present, the administration of a ferruginous tonic, with five 
grains of the iodide of potash three times daily, for from three to six 
months, will often effect a cure of both the laryngitis and the bronchitis. 
One of my patients gained twenty pounds in five months under this 
treatment. 

The hygienic conditions should be good, the living and the sleeping 
rooms ventilated, and proper clothing worn. Even with all these pre- 
cautions it is often impossible to greatly improve the quality of the 
voice. 

(b) Discrete or Localized Hypertrophic Laryngitis. — Synonyms. — Chronic 
subjective laryngitis; laryngitis hypoglottica; chorditis vocalis hyper- 
trophica inferior; Stoerk's blennorrhea. 

Discrete or localized hypertrophic laryngitis is characterized by 
hoarseness or aphonia, dyspnea, a brassy cough, and an infiltration of 
the tissues in the subglottic space. 

Etiology and Pathology. — The pathological changes are the same as 
those given under the diffuse form, except that they are more localized. 

Symptoms. — The subjective symptoms are about the same as those 
given under the diffuse form, but are greatly exaggerated. The hoarse- 
ness usually amounts to aphonia. The hypertrophic tissue in the sub- 
glottic space and the infiltration of the laryngeal muscles, interfere with 
the normal movements of the cords to such an extent that approxima- 
tion is often impossible. The dyspnea, or suffocative symptoms, are 
due to obstruction below the glottis. The brassy cough is characteristic, 
of obstructive swelling and hypertrophy in the subglottic region. 

The objective signs of this variety of laryngitis are quite characteristic. 
The hypertrophied tissue below the cords appears in the form of two 
sausage-like masses, nearly parallel with and beneath the true cords. 
Their color varies from a pale grayish pink to the deep red of active 
inflammation. The epiglottis is also congested, and enlarged blood- 
vessels pass over its posterior surface. In some cases there is more or less 
edema. In these cases deglutition is difficult, owing to the imperfect 
closure of the glottis. The dyspnea in discrete hypertrophic laryngitis is 
increased upon exertion. Patients sometimes complain of a sense of 
stuffiness, or of a foreign body in the larynx. After the disease is well 



CHRONIC LARYNGITIS 469 

advanced, the above symptoms are fairly persistent, as the hypertrophic 
swelling is a fixed factor. Upon attempted phonation the cords fail to 
approximate, and instead of the free edges presenting straight lines they 
are slightly concave or wavy, owing to the weakness of the abductor 
and tensor muscles and infiltration. No doubt the hypertrophic 
masses in the subglottic region also interfere with the movements of 
the cords. The secretions are thick and whitish in color and are 
often accumulated in the interarytenoid space, and over the sluggishly 
moving cords. 

Diagnosis. — Rhinoscleroma presents some points of similarity, but 
in view of the fact that it is a very rare disease in this country, and that 
if the subglottic swelling is touched, under cocaine anesthesia, with a 
probe, it is yielding, whereas in rhinoscleroma it is hard and resistant, 
there is little difficulty in excluding rhinoscleroma. The removal of a 
piece of the growth for microscopic examination may be practised in 
case of doubt. This, when stained by Gram's method (see Rhino- 
scleroma), shows the characteristic cell formation, and the bacillus of 
rhinoscleroma if that disease is present. 

Prognosis. — On account of the hypertrophic swellings below the cords, 
the dyspnea may become so great as to require the performance of 
tracheotomy (see Tracheotomy) and the wearing of a tube throughout 
the remainder of life. The danger from suffocation and the pulmonary 
complications incident to the wearing of the tracheal tube render it a 
grave disease. 

Treatment. — Before undertaking the treatment, the cause or causes of 
the. affection should be carefully studied. When the etiology has been 
definitely determined, an endeavor should be made to overcome the pre- 
disposing causes of the disease. If rheumatism, gout, dyspepsia, anemia, 
or constipation (Watson Williams) are present, appropriate remedies 
should be given. The iodide of potash and the protoiodide of mercury 
should be given whether or not syphilis is suspected, as they often pro- 
mote more or less absorption of the deposit. Tonic remedies, as iron, 
arsenic, quinine, gentian, and strychnine, should be given to promote 
the general tone of the system and to innervate the laryngeal muscles. 
Obstructive lesions and inflammatory diseases of the nasal chambers 
and of the epipharynx should be remedied by appropriate medicinal 
and surgical measures. If the excessive use of tobacco and alcohol 
enter into the etiology, their use should be interdicted. The local appli- 
cation of astringents, as the chloride of zinc (10 to 30 grains to the ounce), 
nitrate of silver (10 to 30 grains to the ounce), alum (5 to 15 grains 
to the ounce), should be made with Sajous' laryngeal forceps or with 
an atomizer during phonation. A change of climate or a sea voyage 
is sometimes beneficial, though not curative. Last, but not of least 
importance, is the absolute rest of the vocal organs. Great improve- 
ment sometimes results when these precautions are faithfully observed 
for a few days. 

(c) Chorditis Nodosa.— Synonyms. — Trachoma of the vocal cords; 
chorditis tuberosa; singers' nodules. 



470 DISEASES OF THE LARYNX 

Chorditis nodosa is characterized by the formation of nodules along 
the free border of one or both of the vocal cords. Some authors claim 
that they are more often near the junction of the middle and posterior 
thirds of the cords, though others have observed them at the junction 
of the anterior and middle thirds. In my cases they have been in the 
former position. 

Etiology. — The nodules usually complicate chronic hypertrophic laryn- 
gitis in singers and public speakers who use faulty methods of respiration 
and voice placement (Curtis). Curtis insists that his patients practice 
lower costal respiration with the upper ribs elevated, and that they 
practise voice placement by attacking the initial tone with the lips 
gently closed, as in humming, so that when they are plucked with the 
finger the tone flows therefrom. If the tone does not emit through the 
lips when plucked, but comes through the nasal chambers only, it is 
an evidence of faulty voice placement. When such is the case there is 
an overtension of the intrinsic and extrinsic muscles of the larynx. This 
causes attrition of the cords at the tips of the arytenoid processes, hence 
the nodules at this position. Singers' nodules of this type may be likened 
to corns due to ill-fitting shoes. Chiari claims that chorditis nodosa is 
a typical pachydermia laryngis. Hajek thinks the nodules are gland- 
ular hypertrophies. The term as herein used refers to nodules from 
improper voice placement. 

Pathology. — The nodules consist of layers of stratified squamous 
epithelium surrounded by a circle of congested tissue. 

Symptoms. — As the nodes accompany a diffused hypertrophic laryn- 
gitis, the symptoms are sometimes similar to those described under that 
condition. The special subjective symptoms are that the singer or the 
public speaker is unable to strike the tone he desires, especially in the 
middle register. When the cords are widely separated, as in the lower 
register, no difficulty is experienced, as the opposing nodes do not touch. 
When the higher register is attempted, the posterior thirds of the cords 
are necessarily closely approximated and not in use, and the voice is 
not greatly affected. When, however, the middle register is attempted, 
the cords vibrate their entire length, and as the nodes touch they interfere 
with voice production. Hence, a prominent symptom is the difficulty 
in tone placement experienced by singers in attempting to use the voice 
in the middle register. The laryngoscopic image shows a nodule on the 
free border of one or both cords, usually at the junction of the posterior 
and the middle thirds, though the nodules may occasionally form any- 
where along their borders. If both cords are involved, the nodules are 
exactly opposite. A small area of hyperemia is often present at the base 
of the nodule. If diffused hypertrophic changes are present, they may 
not be apparent except as shown by the hyperemia. 

Prognosis. — The prognosis in regard to the disappearance of the 
nodules is good, provided the patient faithfully follows the instructions 
contained in the chapter on the Singing Voice, or practises external 
massage of the larynx, as recommended by Miller. 



CHRONIC LARYNGITIS 471 

Treatment. — The treatment consists in refraining from singing and 
loud speaking, and in practising proper methods of breathing and tone 
placement. This should be done under an intelligent and appreciative 
instructor, which, alas! is hard to find. I have treated a few cases of 
"singer's nodules," according to Curtis' suggestions, with most excellent 
results. In none of the cases did I resort to either local, medicinal, or 
surgical treatment, as the nodules were apparently the result of faulty 
methods of singing. 

If advisable, the astringent remedies described under discrete hyper- 
trophic laryngitis may be used. In extreme cases, it may be necessary 
to remove the nodules with an intralaryngeal cutting forceps introduced 
by the direct or indirect method. This should be done only after failure 
to cure by the other methods suggested. Miller recommends external 
massage of the larynx with a mechanical vibrator as an adjunct to proper 
training in tone building and voice placement. The massage improves 
the circulation and nutrition of the mucous membrane, increases 'the 
local migration of leukocytes, and relieves the associated laryngeal 
inflammation. 

Atrophic Laryngitis.— Synonym. — Laryngitis sicca. 

Atrophic laryngitis is characterized by a burning or pricking sensa- 
tion after exercising the voice and by suffocative attacks (simulating 
spasmodic croup and asthma) during the night. 

Etiology. — The atrophic changes in the larynx are usually secondary 
to the same process in the nose and pharynx. Bosworth believes that 
some influence is brought to bear upon the mucous glands of the laryn- 
geal mucous membrane, which deprives them of their secretory power, 
and that this influence is often independent of intranasal or pharyngeal 
atrophy. According to my observation, atrophic laryngitis is often sec- 
ondary to ethmoiditis and sphenoiditis, and I usually address therapeutic 
measures to these cavities as well as to the larynx. 

Pathology. — The mucous membrane undergoes a retrograde change, 
and fibrous tissue finally replaces the normal elements constituting the 
mucous membrane and submucous tissue. The mucous glands and 
the bloodvessels disappear, or become greatly diminished in size. The 
ciliated columnar epithelium is gradually replaced by squamous epithe- 
lium. The secretions are diminished in quantity and changed in quality. 
They are thicker and admixed with white corpuscles and epithelial 
debris. The desiccated secretion appears as brownish, blackish, or 
grayish crusts on the cords, and in the interarytenoid space. Ulceration 
of the mucosa is not generally present, though it may be, especially 
on the posterior wall. 

Symptoms. — After using the voice, there may be a burning or pricking 
sensation in the throat. Cough of a hoarse, spasmodic character is 
excited by the presence of, and the attempt to remove, the crusts from 
the larynx. The cough and hoarseness are more severe in the morning. 
Dyspnea, simulating spasmodic croup or asthma, may occur at night 
on account of the accumulation of the crusts over the vocal cords. I pon 
laryngoscopic examination the mucous membrane appears pale and 
dry, with discolored crusts on the cords, or in the interarytenoid space. 



472 DISEASES OF THE LARYNX 

They may also be seen upon the posterior wall of the larynx in some 
cases, especially if there is ulceration in this region. The cords are 
dry and wrinkled and more or less covered with crusts. The trachea 
may be dry and glazed or covered with crusts. 

Prognosis. — The prognosis is bad except in those cases in which the 
atrophic changes have progressed but little. In such cases the surgical 
exenteration of the ethmoid and sphenoid sinuses may effect a cure or an 
amelioration of the disease, provided, of course, the sinuses are affected. 

Treatment. — The internal administration of the iodides occasionally 
stimulates glandular activity, and thus affords relief. Pilocarpine may 
also be given for the same purpose if the heart is strong. It should never 
be given unless an examination of this organ has first been made. The 
chloride of ammonium and cubebs stimulate the glands and thin the 
secretions, rendering them easier to dislodge. The inhalation of aro- 
matics in solution in olive oil, thrown into the larynx with a nebulizer, is 
grateful and affords temporary relief. Medicated lozenges with a mucila- 
ginous base may be used to protect the dry membrane. A warm, moist 
climate or a sea voyage will ameliorate the symptoms. Careful attention 
should be given to the condition of the nose, the accessory sinuses, and 
the pharynx. If the nose is kept free from crusts and the secretions 
are increased the larynx will undergo a corresponding improvement. 
In empyema of the posterior ethmoidal and the sphenoidal cells, the 
secretions discharge into the pharynx and trickle downward into the 
larynx, where they become dried and adherent to its posterior wall, or 
lodge upon the cords. In such cases great improvement follows the 
radical operative treatment of the sinuses. 

Hemorrhagic Laryngitis. — Synonyms. — Spurious hemoptysis; laryn- 
geal hemorrhage; bleeding in the throat; spitting blood. 

By hemorrhagic laryngitis is meant a laryngeal inflammation accom- 
panied by hemorrhage from the laryngeal mucous membrane. The 
spitting of blood, or hemoptysis, is not always of laryngeal origin. It 
may come from the nose, the pharynx, the trachea, the bronchi, or the 
lungs. The term hemoptysis, or spitting of blood, should be limited 
to hemorrhage from the lungs, and especially that which occurs in 
tuberculosis. 

Etiology. — Hemorrhage which occurs in the course of laryngitis is due 
to ulcerations, acute inflammations, and to excessive use of the voice. 
Syphilis and tuberculosis of the larynx may be attended with laryngeal 
hemorrhage. Albuminuria, diabetes, variola, typhoid fever, yellow 
fever, leukemia, hemophilia, and malignant disease also predispose to 
hemorrhages. 

Symptoms. — If chronic laryngitis is present, the usual symptoms of 
such a condition are also present. (See Chronic Laryngitis.) The 
patient also complains of a tickling sensation in the throat, followed by 
cough and the expectoration of blood. The quantity varies from a mere 
streak to a mouthful; usually, however, it is small. 

The laryngoscopic examination shows one or more areas of extrav- 
asated blood in the cords or mucous membrane, and some fresh fluid 
blood may still cling to the surface of the laryngeal mucosa. 



CHRONIC LARYNGITIS 473 

Treatment. — Ordinarily no treatment is required. Astringent sprays 
and the external application of ice may be tried. If the cough continues 
it should be quieted by the administration of morphine by hypodermic 
injection (Coakley). The act of coughing prevents coagulation and 
tends to prolong the bleeding. 

General Diagnosis of Chronic Laryngitis. — The differential diag- 
nosis of chronic laryngitis from other laryngeal disease is not always 
easily made. It may be confounded with laryngeal tuberculosis, syphilis, 
adenitis, carcinoma, and certain benign growths. 

Tuberculosis is characterized by a rapid pulse, elevation of tempera- 
ture, loss of appetite, emaciation, and a general lowered vitality. These 
symptoms are not present in chronic laryngitis. An examination of 
sputum for tubercle bacilli will still further aid in the diagnosis. A 
laryngoscopic examination does not always settle the diagnosis, unless 
the larynx is the seat of the tuberculous infiltration. In most cases of 
tuberculosis the laryngeal mucosa is ashen gray in contrast with the 
diffused hyperemia of chronic laryngitis. In the inflammatory type of 
laryngeal tuberculosis (mixed infection), the mucosa is red, but the 
swelling of the arytenoid cartilages is too great to be mistaken for 
catarrhal inflammation. 

If the tuberculous process is well advanced, ulcerations may be 
present. 

Syphilitic affections of the larynx may present much the same appear- 
ance as the edematous type of chronic laryngitis. Hyperplasia may be 
present in both diseases, but is more often present in syphilis. Careful 
inspection will often reveal small ulcers, which may lead to a mistaken 
diagnosis of syphilis. An accurate history of the case is, therefore, 
necessary in making the differential diagnosis. In the tertiary stage of 
syphilis the diagnosis is easily made. The ulcers in hypertrophic laryn- 
gitis are stationary, while those of syphilis and tuberculosis are deep 
and spread rapidly. 

Carcinoma in the subglottic region is distinguished from discrete 
hypertrophic laryngitis by the nodular outline of the growth and the 
cachexia. Perichondritis in this region more nearly simulates carcinoma 
on account of the nodular outline of the tumor-like mass. 

In lupus the surface of the membrane is markedly red and granular. 

Sarcoma of the larynx presents a red and an uneven contour, whereas 
in all forms of hypertrophy the swelling and purulent discharge come 
before the perichondritis is well developed. 

Enchondrosis of the laryngeal cartilages is differentiated from edema- 
tous laryngitis by the sense of hardness on probe pressure and the uneven 
contour of the swelling. 

Paralysis of the posterior crico-arytenoid muscle may be mistaken 
for subglottic hypertrophy unless a careful examination is made. In 
paralysis the lagging movements of the cords reveal the nature of the 
lesion. The paralysis may also be mistaken for pachydermia laryngis. 

Prolapse of the ventricles is differentiated from superior hypertrophy 
by marked pitting upon probe pressure. 



474 DISEASES OF THE LARYNX 

Angina laryngis is differentiated from hemorrhagic laryngitis by the 
elevated whorl of bloodvessels and the absence of hemorrhage. 

Papilloma is distinguished from chorditis nodosa by the point of 
attachment and the size and shape of the growth. 



DIPHTHERIA; TRACHEOTOMY; INTUBATION 

Definition. — Diphtheria is an acute infectious disease, characterized 
by the presence of the Klebs-Loeffler bacillus. It is still further char- 
acterized by a false membrane on a mucous surface or an abraded skin, 
and is communicable, either directly or indirectly, from one person to 
another. The lesion is usually located in the upper respiratory tract. 

Etiology. — As to its geographical and racial distribution, it may be 
said to be well-nigh universal. No climate, season, country, or race is 
exempt from its ravages. It is, however, less prevalent in the summer 
season in temperate and northern latitudes, on account of the open-door 
life of the people at this season, and because, during the school vacations, 
the overcrowding and the close contact incident to school life are tempo- 
rarily suspended. Statistics show that among the poor in crowded tene- 
ments, and in badly ventilated schoolrooms, the disease is more prevalent. 
A curious exception to this is shown by Walsh to exist among the negroes 
of Washington. The percentage of diphtheria among 10,000 negroes 
was 4.43 as against 15.25 per cent, among the same number of whites. 
This may be due to an antitoxic state of the blood in the negro race, 
or to a greater freedom from disease of the upper respiratory tract. 
(Nasal obstruction is comparatively rare among negroes.) 

Sanitation is an important factor in the development of the disease. 
Sunshine and fresh air are twin sisters of charity in the prevention and 
the amelioration of infectious diseases. In one of the great children's 
hospitals of London, diphtheria was prevalent in one of the wards. As 
soon as they were convalescent, the patients were removed to another 
ward and no recurrences were reported. An adjacent building was torn 
down and the solid iron shutters of the convalescent ward were closed to 
exclude the dust. Incidentally the sunshine and the fresh air were also 
excluded, and there were many recurrences among the convalescents. 

The overcrowded tenement districts in the great cities are usually 
poorly ventilated and the rooms little exposed to the sunshine. When 
many are in close contact, the opportunities for transmitting the infection 
are multiplied; hence, for these and other reasons, the poor of the cities 
are especially afflicted with diphtheria. 

Defective plumbing, sewer gas, cesspools, etc., are thought to produce 
the disease. While these may indirectly influence the spread of the 
contagion, it should be remembered that the Klebs-Loeffler bacillus is 
absolutely essential to the production of the true disease. The presence 
of sewer gas may produce lessened resistance to the diphtheria bacilli, 
and thus predispose the patient to their ravages. 

Bodily conditions have much to do with the susceptibility of the 



DIPHTHERIA 



475 



individual exposed to the Klebs-Loeffler bacillus. The "scrofulous 
habit" lowers the tone of the cellular elements of the body, and thus 
renders it less fit to cope with the inroads of the disease-producing germ. 
Abraded or diseased surfaces in the upper respiratory tract also offer 
local areas of lowered resistance to the growth of the bacilli. Hence, 
enlarged and diseased tonsils, adenoids, glandular enlargements of the 
neck, and catarrhal diseases of the nose and throat favor the develop- 
ment of the diphtheritic process. 

Rich and poor alike are affected, the only difference being the more 
favorable sanitary conditions surrounding the rich, who are, therefore, 
relatively less often affected. 

Age has a great influence on the prevalence of the disease. The 
blood of nurslings is very antitoxic in its properties, hence children 
under one year of age are comparatively exempt from the disease. After 
the fourteenth year there is relatively slight predisposition to diphtheria. 
Babinski shows by the statistics of 2711 diphtheritic cases that under 



Fig. 303 



PERCENTAGE 
OF CASES 


1 2 


3 4 5 


6 


YEAR 

7 8 9 10 Ml 


12 


13 14 


U7c 
13 1c 

121c 
H7< 
107c 
9% 
87c 

11c 

U 

h1c 

4/< 

n 

U 
















































































































































































































































s. 


k, 




























\ 




























































































j 



























































The above chart is arranged from the statistical data of Babinski, and shows at a glance the rela- 
tive prevalence of diphtheria from birth to fourteen years of age. 

six months the percentage of cases is 0.55; six months to one year, 2.5* 
per cent.; one to two years, 8.3 per cent.; two to three years, 11.6 per 
cent.; three to four years, 13.05 per cent.; four to five years, 12.4 per 
cent.; five to six years, 9.7 per cent.; six to seven years, 10.3 per cent.; 
seven to eight years, 7.7 per cent.; eight to nine years, 6.4 per cent.; 
nine to ten years, 5.5 percent.; ten to eleven years, 3.7 per cent.; eleven 
to twelve years, 2.9 per cent.; twelve to thirteen years, 2.02 per cent.; 
thirteen to fourteen years, 2.6 per cent. (Fig. 303). 

Modes of Infection, Direct and Indirect.— The direct infection is from 
the one affected to another, i. e., by breathing the atmosphere immediately 
surrounding the patient, inhaling his breath, or receiving the mucus or 
the saliva into the mouth or the nose during an act of coughing, spitting, 
or sneezing on the part of the patient. Kissing is another mode of direct 
infection, and is to be condemned when diphtheria is known to exist in 
the family. All members of the family should refrain from this manifes- 
tation of affection during the term of diphtheritic infection, as there may 



476 DISEASES OF THE LARYNX 

be a mild or an incipient infection without the knowledge of the indi- 
vidual. Without doubt the disease is often transmitted by persons who 
are not suspected of being infected. 

The indirect mode of infection is not so easily traced as the direct; 
nevertheless, it is well established that the bacilli may be transmitted 
by domestic animals, as dogs, cats, chickens, rabbits, etc., which, being 
directly exposed to the contagion, convey it to persons removed from the 
direct source of infection. The author recalls a case which aptly illus- 
trates this point. He was in the house of a minister when a member of 
the parish called to make the funeral arrangements for his child, who 
had just died of diphtheria. The man was accompanied by a collie, 
which was hugged and fondled by the four-year-old son of the minister. 
Within a few days the boy was ill with diphtheria, having no doubt 
received the infection from the collie. 

It may also be conveyed by towels, table-linen and dishes, bedding, 
books, wall-paper, carpets, rugs, clothing, and all other articles bathed 
in the germ-laden atmosphere surrounding a diphtheritic patient. Food, 
especially milk, may be the source of infection. 

The hands and the clothing of physicians, nurses, and parents should 
be mentioned as sources of infection. 

The custom of serving the elements at communion services in churches 
from common cups is to be condemned as a possible mode of conveying 
contagious diseases. Individual cups should be used, thereby minimizing 
if not absolutely removing the danger. The church should be as cleanly 
in its table manners as its individual members are in their homes. There 
they do not think of drinking from a common vessel, each member and 
each guest being provided with one for his individual use. The same 
decent, cleanly, sanitary custom should prevail in ecclesiastical functions. 

Diphtheria may be endemic, epidemic, or sporadic in its manifesta- 
tions in a community. The mode of manifestation is largely due to the 
density and the numerical strength of the settlement. In large cities, 
where large numbers are congregated in small areas, diphtheria is epi- 
demic, coming as a tidal wave of infection and carrying many away in 
its course. The community may then be free from the disease for months 
or years. The sporadic or isolated cases are more difficult to explain, 
but we know that the Klebs-Loeffler bacilli must be present. They may 
live under varying and peculiar conditions for a long time. The sporadic 
cases are often caused by the germs, which suddenly become virulent 
and give rise to the isolated attacks of the disease. 

Bacteriology. — The Klebs-Loeffler bacillus being the specific cause of 
diphtheria, its characteristics and the method for its detection are im- 
portant. The announcement of Klebs in 1883 that he had discovered a 
bacillus which was constantly present in the false membrane of diph- 
theritic patients, marked an epoch in the history of medicine, and soon 
revolutionized the methods of treating diphtheria. Loeffler in 1884 made 
pure cultures of the bacilli, and inoculated the mucous membranes of 
animals, getting the characteristic pseudomembrane of diphtheria. In 
1888-89, Roux and Yersin reported the results of their experiments 



DIPHTHERIA 477 

relative to the toxins produced by this germ. Serumtherapy thus had 
its beginning. 

The Klebs-Loeffler bacilli vary greatly in size, shape, and curvature, 
according to the medium in which they are grown, and often vary in the 
same medium. They also vary with the fluidity, the age, and the tempera- 
ture of the medium, but they generally present the appearance of narrow 
rods, straight or curved, swollen at either extremity, and are found in 
groups with a tendency to parallelism. They are not always parallel, 
but may have a tangled, irregular arrangement, or be in broken chains. 

The atypical forms may be thickened at one end only, or at the centre 
of the rod, the extremities being pointed. They may also be lance-, 
spindle-, or club-shaped, or even pear-shaped. One characteristic is 
always present, namely, segmentation, 

The Klebs-Loeffler bacilli stain readily with alkaline methylene blue 
and many other aniline dyes. 

Northrup gives the following directions for the preparation of Neisser's 
stain and its application to the differentiation of the diphtheritic germ: 

"No. 1. — 1 gm. methylene blue dissolved, 20 c.c. of 96 per cent, alcohol, 
90 c.c. distilled water, 50 c.c. glacial acetic acid. 

"No. 2. — 2 gm. vesuvin to 1 liter of boiling distilled water. 

"The culture is stained in No. 1 for one to three seconds, or even 
somewhat longer; washed off in water and stained with No. 2 for three 
to five seconds or longer; washed off and mounted. Colored in this 
way, a twenty-four-hour-old culture on blood serum or bouillon will 
show the body of the bacilli stained brownish yellow, while at one or both 
ends may be frequently seen the so-called polar granules (Neisser-Ernst 
bodies) as deeply colored blue, oval-shaped areas, the diameter of which 
is greater than that of the bacillus in which they are found. The out- 
lines of these bodies are sharply defined, and they are not peculiar to 
true diphtheria bacilli, but are found occasionally in a slightly atypical 
form in certain forms of pseudodiphtheria bacilli, especially in older 
cultures." 

The diphtheria bacilli may be grown upon blood serum, agar-agar, 
bouillon, milk, etc., and they are pathogenic for pigeons, rabbits, guinea- 
pigs, chickens, certain small birds, cattle, goats, and horses. 

Bacteriological Diagnosis. — A portion of the pseudomembrane should 
be removed from the throat of the patient with an aseptic cotton-wound 
probe, wire loop, or other instrument, and smeared over a clean cover- 
glass, dried and stained with Roux's double stain of dahlia violet and 
methyl green or with Loeffler's blue-staining solution. 

The coverglass thus prepared should be mounted and examined with a 
microscope. The diphtheritic bacilli, if present, will be readily recog- 
nized by their typical appearance. If not found, a culture in blood serum 
should be made, which, in from twelve to twenty-four hours, in a tempera- 
ture of 37° C, will develop grayish colonies, the size of a pinhead, with 
regular outline, the surface being dry. Held to the light, the periphery 
is translucent, the centre being somewhat opaque, on account of its 
greater thickness. 



478 DISEASES OF THE LARYNX 

Upon the above appearances and reactions a fairly positive diagnosis 
of diphtheria may be made. ^ 

The development of the streptococcus is much slower (twenty-four to 
seventy-six hours), the colonies are white, and pinpoint in size. 

The development of the staphylococcus is slower than that of the 
diphtheritic bacillus, but faster than that of the streptococcus. It pre- 
sents the appearance of a flocculent or white colony much larger than a 
pinhead, and has a halo-like border. The areas are darker in the centre. 

A negative result with the microscopic examination, or with the cul- 
tures, does not justify a positive statement that the case is not one of true 
diphtheria. The author knows of an instance in which seven different 
examinations were made by an expert bacteriologist and pathologist, 
before the Klebs-Loeffler bacilli were found. 

Mixed infection generally occurs, hence a case of simple diphtheria is 
not commonly seen in practice. The Klebs-Loeffler bacilli are usually 
associated with streptococci, staphylococci, and diplococci, and the symp- 
toms and the progress of the disease are modified accordingly. Again, 
virulent diphtheria bacilli may be present in a healthy throat without 
giving rise to any symptoms. Should, however, these same bacilli be 
lodged in a throat with enlarged, ragged tonsils, there is every prob- 
ability that the person would be affected by true diphtheria. Mixed 
infections are more serious than simple ones, as the accessory germs may 
produce severe pathological changes, independent of the diphtheritic 
process. 

The Systematic Distribution of the Bacilli.— Many investigators 
report the presence of Klebs-Loeffler bacilli in pneumonic areas and 
lymphatic glands, but they are generally associated with other germs. 
They have been found in the lungs, the spleen, the bone-marrow, 
the liver, the nasal accessory sinuses, the heart's blood, and they are 
probably in other tissues of the body. 

Pseudodiphtheria Bacilli. — There are two schools of thought regarding 
the so-called pseudobacilli of diphtheria: (a) The larger school holds 
that the pseudodiphtheria bacillus is under no circumstances convertible 
into the true diphtheria bacillus, (b) The smaller school holds that 
the two germs are identical. The scope of this work will not permit of 
a presentation of the data upon which these two schools of thought rest 
their claims. Suffice it to say that the two germs are differentiated, 
according to the first or larger school, by their mode of development on 
various culture media, their morphology, and their pathogenicity. 

Histopathology. — The distribution of the false membrane may involve 
the mucous membrane of the nose, pharynx, tonsils, hard and soft 
palate, mouth and lips, larynx, trachea, the bronchi from the largest 
to the smallest, the ear, and abraded surfaces of the skin. The vagina, 
the duodenum, the conjunctiva?, and other mucous membranes may 
also be involved. 

In about 75 per cent, of the cases the membrane is above the larynx. 
In 15 per cent, of the cases the larynx is involved. Previous to the use 
of antitoxin, autopsies often showed the pseudomembrane extending 



DIPHTHERIA 479 

from the tip of the nose to the smallest bronchi; since the use of anti- 
toxin it is rarely found so extensively distributed. 

The appearance of the pseudomembrane varies from a grayish white 
through a dirty brown to a black color (in hemorrhagic diphtheria). 
Its consistency is usually tough and leathery, although it may be friable. 
It is firmly attached to the underlying tissues when* found on the uvula 
or the pharyngeal wall, and loosely attached in the trachea. 

The formation of the pseudomembrane begins with an exudation of 
lymphatic cells, which rapidly undergo coagulative necrosis, leaving 
a reticulated substance composed of fibrin from the broken-down cells. 

If the fibrin penetrates the deeper layers of the mucosa, it is difficult 
to remove it, as the line of demarcation is not easily established between 
the living and the dead tissue. If, on the other hand, the fibrin remains 
superficially attached, it is easily removed, for obvious reasons. When 
the pseudomembrane is deeply attached, its removal is attended by some 
bleeding; if superficially attached, there is no bleeding. 

Sloughing of the mucous membrane may occur when the bloodvessels 
supplying it become degenerated, thrombosed, or otherwise injured, so 
that the nutrition supplied to the parts is shut off. This is often spoken 
of as " gangrenous diphtheria." 

It is seen by the foregoing statement of the varying appearances 
and conditions of the pseudomembrane of diphtheria that the picture 
presented is kaleidoscopic in character. Its appearance in the early 
stage is usually as a whitish or yellowish, circumscribed film, and, at 
a still later period, it may become yellowish or dirty brown in color. If 
hemorrhage takes place beneath or within the false membrane, it may 
become black. 

According to Northrup, the pathological changes in various parts of 
the body have been shown by numerous writers, and only a brief 
mention of them can be made here. 

The nervous system is involved in some cases with degeneration of 
the posterior roots (Bikeles and Kalisko), where they enter the gray 
matter of the posterior cornua, thus accounting for the ataxic symptoms 
which occur in diphtheritic paralysis. Manicatide reports his findings 
as follows: 

(a) Purely muscular changes with no nerve involvement. 

(b) Polyneuritis. 

(c) Lesions of the spinal cord, which were either localized in the gray 
matter, leading to atrophy of muscles, or involving the white matter of 
the cord, in a similar way to that seen in locomotor ataxia or multiple 
sclerosis. 

(d) Cerebral paralysis, chiefly due to circulatory changes. 

The heart undergoes degeneration, chiefly fatty. This simple type 
of degeneration precedes the more destructive hyaline changes, which 
lead to the loss of the sarcous elements. The changes are due to 
toxins. 

The lungs are, in about 60 per cent, of cases, affected by broncho- 
pneumonia. True lobar pneumonia has not been found. 



480 DISEASES OF THE LARYNX 

The splee?i is affected by cell infiltration in the splenic follicles. In the 
centres of the follicles, masses of epithelial cells are sometimes found. 
There is local edema of the centre or the periphery of the follicles. 
Necrotic areas and hyaline changes are also present. 

The lymphatic glands first undergo congestion and hemorrhage, and 
there is dilatation of the lymphatic sinuses. Later, foci very similar 
to miliary tubercles form, by a process of proliferation, phagocytosis, 
and degeneration. These changes are due to the toxins formed by the 
lymphatics and not to bacteria. The same changes, with minor modi- 
fications, take place in the tonsils. 

The thymus gland undergoes the same changes as described under 
lymphatic glands. 

The skeletal muscles undergo fatty degeneration. 

The bone marrow undergoes hyperplastic changes. 

The pancreas has not been found involved in autopsies following true 
diphtheria. Hibbard and Morrissy found glycosuria in 25 per cent, 
of 230 patients. Others have failed to find it so commonly present. 
Examinations for sugar should be made in every case of diphtheria. 

The alimentary canal may be affected by true diphtheria of the stomach. 
The pseudomembrane has not been found in the intestine. 

The liver undergoes degenerative changes, ranging from simple fatty 
to hyaline degeneration. Focal necrosis is the most characteristic change 
in this organ in diphtheria. 

The kidneys undergo fatty and hyaline degeneration. Casts are 
present. There are also interstitial changes in about 25 per cent, 
of cases examined. There is an increase in the cells of the glomeruli, 
and sometimes necrosis with hemorrhage into the capsular space is 
present. 

Types of Diphtheria. — Before considering the symptomatology, it 
will be well to consider briefly the various types of diphtheritic mani- 
festations. It is often described, according to the seat of local manifesta- 
tion, as angina, local or general; nasal diphtheria; bronchial diphtheria; 
broncholaryngeal (ascending) diphtheria; conjunctival diphtheria; aural 
diphtheria; vaginal and rectal diphtheria, etc. 

Monti's classification, according to Northrup, in NothnagePs Encyclo- 
pedia of Practical Medicine, is as follows: 

Catarrhal Diphtheria (Bacteriological Diphtheria; Diphtheria Fruste). — 
This type is characterized by simple redness and swelling of the tonsils 
and the pharynx, with no false membrane. Microscopic examination 
shows the Klebs-Loefner bacilli present. Spontaneous recovery occurs 
in a few days. The germs, transplanted into another throat, might give 
rise to a more severe type. Careful quarantine should be maintained 
to prevent the spread of the disease. 

Fibrinous Diphtheria. — This type is due to the action of the Klebs- 
Loeffler bacilli uncomplicated by any other germ. It may be purely 
local in its character, the membrane and the slight redness surrounding 
it being the only symptoms; or it may be general, with a tendency for 
the false membrane to spread to other parts, with great toxemia and 



DIPHTHERIA 481 

severe complications. It is more often local in its manifestations. Micro- 
scopic findings: the Klebs-Loeffler bacilli. 

Mixed, Phlegmonous, or Streptodiphtheria. — This type is characterized 
bv great inflammatory reaction in the neighborhood of the pseudomem- 
brane, and by the presence of the Klebs-Loeffler bacilli with some other 
pathogenic organism, usually the streptococcus, and their toxins. Mixed 
infections are more dangerous, and experiments on animals (Roux and 
Martin) show that antitoxin has little or no effect in checking the ravages 
of this type of infection. 

Septic or Gangrenous Diphtheria (Septicemia). — In dealing with this 
tvpe, we are essentially treating septicemia of diphtheritic or of mixed 
infectious origin. It is usually of mixed infection (Klebs-Loeffler, strepto- 
cocci, and staphylococci) origin, although in rarer cases it seems to 
originate from the simple Klebs-Loeffler bacillus infection, which has 
assumed the so-called gangrenous diphtheria type. In other words, 
what started out as a simple diphtheria later became complicated by 
other germs and their toxins, a true septicemia resulting. It is doubtful 
if true septicemia ever results from pure Klebs-Loeffler bacillus 
infection. 

General Symptomatology. — The disease is ushered in by a feeling of 
discomfort, lassitude, loss of appetite, constipation, slight sore throat, 
difficulty in swallowing, and more or less hoarseness. 

The temperature varies with the type, but has certain characteristics 
which may be recognized. For instance, even in the fibrinous type, 
which is the least febrile, there is a rise of temperature with the beginning 
of the formation of the membrane. It is commonly said that this type is 
not attended with fever. Notwithstanding, it will be found that there will 
be a recurrence of elevated temperature with each extension of the pseudo- 
membrane to a new part. In all types of diphtheria there is an increase 
of temperature with each extension of the local field of infection. There 
is a greater fluctuation of the temperature curve in the mixed infec- 
tion and the septic type than there is in the catarrhal and the fibrinous 
varieties. 

The pulse rate is invariably increased in uncomplicated cases in the 
beginning, in proportion to the toxic products eliminated. The pulse 
rate in infants is especially high. 

Brachycardia (slowing of the pulse rate), if persistent, is a grave 
symptom. 

Tachycardia (increased pulse rate), when reaching a rate of 140 or 
more, is a grave symptom. At 140 the death rate is about 20 per cent., 
increasing to 90 per cent, at a pulse rate of 180. Nasal diphtheria is 
usually the cause of the tachycardia, hence the occurrence of a rapid 
pulse should at once lead to a critical examination of the nasal fossae. 
The nose is very richly supplied w T ith lymphatic tissue, hence the rapid 
absorption and the toxic symptoms. 

Reduced blood pressure, as shown by sphygmographic tracings, indi- 
cates an increased absorption of diphtheria toxins, and warrants a grave 
prognosis. The same is true of an intermittent pulse, 
31 



482 DISEASES OF THE LARYNX 

Partial angina is the most common anatomical form of the disease. 
Early there is a general redness of the pharynx and the pillars of the 
fauces. At the site of pseudomembrane formation, which is usually 
the tonsil, there is increased redness. It may form, however, on the 
posterior pillars, the uvula, or the walls of the pharynx. First one tonsil 
is involved, then the other. The cervical glands are somewhat swollen 
and tender. The temperature is elevated 1 ° to 2°, with frequent oscilla- 
tions. The general health is good. There is transient albuminuria. The 
course is from six to eight days. 

General or toxic angina is characterized by a thicker and more exten- 
sive pseudomembrane, gray or dirty yellow in color, or even brown or 
black. The whole, or nearly the whole, of the tonsils, the pillars (arch), 
the uvula, and the pharynx are covered by the membrane in from three 
to six days. Grave symptoms appear early, and are usually ushered in by 
a chill followed by fever. Delirium, restlessness, apathy, and vomiting 
are often present. Swallowing becomes difficult on account of the 
swollen and stiffened condition of the fauces and the pharynx. The 
epipharynx (nasopharynx) is filled with tenacious mucus. The cervical 
glands are swollen and tender. Albuminuria is severe. Without treat- 
ment, the pseudomembrane may be cast off and be reformed, continu 
ing thus for three to six weeks. Under proper treatment the disease 
may be brought under control in from three to six days. 

Phlegmonous or streptodiphtheritic angina involves the entire throat 
from the beginning. The mucous membrane is dark red, and the uvula 
swollen. Within a few hours a dirty gray or blackish membrane forms, 
and rapidly spreads. The cervical glands are much swollen and very 
tender. While the membrane is forming and spreading, the temperature 
is elevated. Toxic symptoms, as rapid pulse, delirium, restlessness, 
apathy, etc., set in after the membrane has reached its limit. The tem- 
perature usually drops at this time. Albuminuria often appears within 
forty-eight hours. Under antitoxin treatment the disease may be con- 
trolled in from five to six days. In obstinate cases the kidneys and the 
heart may become involved and thus complicate the case. 

Septic angina is characteristic of certain epidemics, although it usually 
develops from the phlegmonous variety. The symptoms are most grave 
from the beginning. Vomiting is violent and attended with extreme 
prostration. The temperature curve rises very suddenly. The pulse 
is small, soft, and rapid. Respiration is increased proportionately. 
The tonsils and the fauces are swollen. They are a livid bluish white, 
with discolored spots. Bloody matter is mixed with the exudate. The 
cervical glands are very much swollen and tender on both sides. Death 
occurs usually on the second to the fourth day, from collapse and general 
sepsis. 

Diphtheria of the nose may assume any one of the foregoing types, 
although it is probably more often of the simple fibrinous type. It 
may be primary or secondary. The upper lip is excoriated by the nasal 
discharge. The child " snuffles," sleeps a great deal, and takes food 
poorly on account of the nasal occlusion, and he may become cyanotic 



DIPHTHERIA 483 

in attempting to nurse the breast. The glands of the neck are swollen. 
Nasal hemorrhages occasionally take place. Many cases run a benign 
course, while others are malignant from the beginning, death occurring 
within a few days. In older children the disease runs a more favorable 
course. In scrofulous children it may be more chronic, often extending 
over many weeks. 

The nasal occlusion is at first thought by the parent to be due to a 
foreign body in the nose. The membrane is usually situated on the 
septum, although it frequently involves the whole Schneiderian mem- 
brane, and may be removed with the forceps or. the syringe, as a cast of 
the interior of the nose. 

In phlegmonous, mixed, or streptodiphtheria of the nose, the symptoms 
are more severe from the beginning, the membrane is mixed with blood 
and appears black (black diphtheria). Toxic symptoms are marked, 
and the glands of the neck much swollen and tender. The patients 
are little inclined to take food. Early and vigorous treatment is often 
followed by recovery. The disease is, however, to be regarded as very 
grave in its nature. On account of the rich lymphatic supply of the 
nose, the septic form of nasal diphtheria is especially serious. 

Laryngeal Diphtheria (True Croup; Membranous Croup; Diph- 
theritic Croup, etc.). — Laryngeal diphtheria may be primary, although 
it is usually secondary to diphtheria of the nose, the pharynx and tonsils, 
the trachea and the bronchi. On account of the great danger, and at 
the same time a possibility of a favorable issue under proper treatment, 
we will, according to Northrup, enter into a brief but careful analysis 
of this type of diphtheria. It should be studied under three headings, 
namely: (1) Stage of invasion; (2) stage of spasm — exudation; (3) stage 
of asphyxia. 

Stage of Invasion. — This is characterized by a simple angina becoming 
suddenly complicated with hoarseness, and a cough characteristic of 
laryngeal irritation. The Klebs-Loeffler bacillus may or may not be 
found. A negative finding is not conclusive, however, as heretofore stated. 

Stage of Spasm (Exudation) .—The pseudomembrane may develop so 
rapidly that within twenty-four hours there is laryngeal stenosis. The 
cough is dry, short, and hoarse, becoming paroxysmal in character and 
often lasting for several minutes. It is attended with cyanosis, full 
veins, and a perspiring forehead. Aphonia, more or less complete, soon 
develops. The respiration is wheezing and noisy. As the stenosis 
becomes more advanced, the inspiratory act is prolonged and is attended 
with a whistling noise. There is pronounced depression of the supra- 
clavicular region, the neck, and the epigastrium. The severe symptoms 
come in waves; extreme cyanosis, and harsh, difficult respiration, which 
gives way, temporarily, thus affording the sufferer a brief respite from 
the aggravated symptoms. The natural duration of the stage is from 
one-half to seven days. 

Stage of Asphyxia. — This stage is characterized by greatly impeded 
respiration and toxic symptoms. The respiration becomes more rapid 
and irregular, the child sits up suddenly and falls back again exhausted. 



484 DISEASES OF THE LARYNX 

The cyanosis and the retraction of the supraclavicular, the jugular, and 
the epigastric regions are more pronounced. The suffocative attacks occur 
more frequently. The head is thrown back, and all the accessory muscles 
of respiration are called into action. Even the abdominal muscles are 
retracted. The larynx rises with each respiratory effort. During one 
of the suffocative attacks, complicated with convulsions, death comes. 
According to Monti, in untreated cases the death rate is from 95 per 
cent, to 98 per cent. Under modern methods of treatment, the death 
rate is small in cases taken early. 

Phlegmonous or Mixed Infection of the Larynx. — It is usually secondary 
to a similar process in the nose or the throat, and is characterized by 
great redness of the mucosa of the larynx and the trachea, with some 
grayish pseudomembrane scattered here and there in the larynx and the 
trachea. The stenosis of the larynx is not so marked as in the preceding 
type, nevertheless, death may occur suddenly from it. The toxic symp- 
toms are also marked in this type, and no doubt contribute toward 
a fatal result. 

Septic Diphtheria of the Larynx. — This is also secondary to a similar 
process in the nose or the throat, or both, and begins with fever, apathy, 
and marked weakness. The mucous membrane of the larynx and the 
nose is swollen, and covered with a grayish-yellow exudate. Toxic 
symptoms, as vomiting, delirium, suppression of urine, heavily coated 
tongue, rapid pulse, etc., are marked. The prognosis is quite grave. 

Causes of Asphyxia in Diphtheria. — Four theories have been advanced: 
(a) Spasm of the glottis; (b) obstruction by pseudomembrane; (c) para- 
lysis of the dilators of the glottis; (d) excitation of the respiratory centres 
by carbonic acid poisoning and reflex action of the pneumogastric 
nerve. 

Autopsies have shown many instances of death from asphyxia when 
there was little or no false membrane to account for it. This leaves spasm 
of the glottis, paralysis of the dilators, and the irritation from carbonic 
acid as possible theoretical explanations. The latter two have but few 
supporters; hence, the probable explanation of the majority of cases is 
to be found in the first theory, namely, spasm of the muscles of the 
larynx. 

Diphtheria of the Trachea and the Bronchi.— This is usually second- 
ary to laryngeal diphtheria, although it may occur primarily in the bronchi 
or the trachea. W Tiere it thus forms, and the larynx' is secondarily 
involved, it is known as "ascending croup." If a cast of the bronchi is 
coughed up, it is a positive sign of bronchial involvement. Other signs, 
as respirations (50 to 60 per minute), continuous dyspnea (as contrasted 
with intermittent when the pseudomembrane is in the larynx and upper 
trachea), supraclavicular and epigastric depressions not so well marked, 
pale face, blue lips, and great physical depression, may aid in reaching 
a diagnosis of bronchial diphtheria. The prognosis is very grave. 

Diphtheria of the Ear.— This is usually carried to the external ear 
by scratching (abrasion) with the infected fingers of the patient. Infec- 
tion of the external auditory meatus is seen in rare instances in which 



DIPHTHERIA 485 

there is diphtheritic otitis media with extension through the tympanic 
membrane. 

Otitis media as a complication of diphtheria, occurs in only about 4 to 
6 per cent, of the cases. When present, it is characterized by deafness 
and pain in the ear upon swallowing and coughing; these are followed 
by aural discharge, after which the pain subsides. 

Diagnosis. — The differential diagnosis of diphtheria should be made 
between (a) peritonsillar abscess; (b) follicular tonsillitis; (c) pseudo- 
diphtheria; (d) pseudocroup; and (e) catarrhal rhinitis; the chief diag- 
nostic point in each case are the microscopic and the culture findings. 

Prognosis. — This may be summarized under the following headings: 

(a) The Age of the Patient. — The mortality is the lowest in the first 
year and the tenth year, and the highest in the second to the sixth year 
of life. 

(b) The Site of the Local Lesion. — Involvement of the larynx results 
in the highest mortality. Nasal diphtheria in infants is very fatal. 

Treatment. — The administration of antitoxin has reduced the cases 
coming to operation one-half. The death rate in laryngeal cases under 
antitoxin has been reduced from 70 per cent, to 16 per cent. Intubation 
is attended with a lower rate of mortality than tracheotomy. 

Time of Beginning Treatment. — Briggs and Guerard have compiled 
the following table: 

Mortality. 

Cases. Deaths. Per cent. 

First day of disease 1415 5 3.5 

Second day of disease 2640 213 8.0 

Third day of disease 2340 300 12.8 

Fourth day of disease 1458 346 23.6 

Fifth day of disease 1912 671 35.0 

It will be seen by the foregoing table that early treatment influences 
the prognosis very favorably. 

Complications and Sequelse of Diphtheria. — Adenopathy.— Swelling 
of the lymphatic glands in the region of the local diphtheritic lesion 
usually occurs. The cervical glands and the tonsils are accordingly most 
commonly affected. After these come the bronchial, the intestinal, and 
the mesenteric glands. 

In the "pure diphtheria, i. e., the simple fibrinous type, the glands are 
swollen, slightly tender, and freely movable in the surrounding tissue. 

In the mixed forms of infection there is greater swelling and tenderness, 
the glands being lost to the touch in the surrounding swollen and infil- 
trated tissue. In some cases the swelling is enormous, constituting the 
symptoms known as "le con proconsulair." Suppuration occurs only 
occasionally, and then only in the mixed type. In the septic type, gan- 
grenous sloughing may occur. Treatment often results in recovery 
from even severe diphtheritic adenopathy. 

Gastro -intestinal. — Vomiting, loss of appetite, diarrhea, and diphtheria 
of the esophagus and the stomach sometimes occur. 

Urine. — The urine is variable in quantity and chemical proportions. 
Albuminuria is present in about one-half of all cases of diphtheria 



486 DISEASES OF THE LARYNX 

and in nearly all cases of the toxic varieties. It is generally due to 
degenerative changes in the kidneys. Hyaline, granular, and epithelial 
casts may be found. 

According to Simon, in diphtheria a well-marked increase of urine is 
the rule, with the exception of very mild or extremely severe cases, 
of constant occurrence. It is interesting to note that, barring a tempo- 
rary diminution immediately after the injection, the leukocytosis is 
nowise influenced by the antitoxin treatment. 

Hyperleukocytosis. — This exists in nearly all cases, and varies accord- 
ing to the toxemia and the sepsis. It may be so severe as to constitute 
a true leukemia. 

Heart Lesions. — Endocarditis, myocarditis, waxy degeneration, nerve 
degeneration, heart clots, and dilatation have been found in certain 
cases which were examined post mortem. 

Nervous Affections. — Degeneration of nerve tissue, paralysis, lessened 
functional activity, etc., sometimes attend, but more often follow, an 
attack of diphtheria. 

Postdiphtheritic Paralysis. — Postdiphtheritic paralysis usually affects the 
velum palati (benign and discrete form) and the pharynx. The chief 
symptom is difficulty in swallowing and the return of liquids through 
the nose. Each act of swallowing is accompanied by a laryngeal cough. 
The voice is nasal, articulation is very much interfered with, and the 
patient snores during sleep. The paralysis disappears in from one to 
three weeks. 

In the general or diffused postdiphtheritic paralysis, the palatal and the 
neighboring muscles are involved. The muscles of the eye are most 
frequently affected. Unequal pupils, diplopia, strabismus, or ptosis may 
be present. Complete recovery eventually takes place. The patellar 
reflex is impaired, or lost, and the muscles of the feet may be paralyzed. 
The patients shuffle their feet on the floor in walking. "Diphtheritic 
pseudotabes/' or even complete paralysis of the lower extremities, may 
complicate some cases. The muscles of the upper extremities are less 
often affected. The muscles of the neck and the head are rarely involved. 
If they are, the child's head falls over on his shoulder. The facial expres- 
sion may be lost, giving an idiotic cast to the countenance. 

Diaphragmatic paralysis occurs in about 7 per cent, of cases, and may 
lead to a fatal termination. The chief sign of diaphragmatic paralysis 
is a sinking in of the abdomen during inspiration, and distention during 
expiration. Respiration is rapid and panting. Bronchitis or other 
slight lesion of the lower respiratory tubes may lead to asphyxiation and 
death. 

Cardiac or vagus paralysis complicates about 1 per cent, of the cases. 

Skin. — Erythema, papular eruption, brownish discolorations, and 
eruptions of the skin, like those of measles and scarlet fever, may 
complicate the disease. 

Bronchopneumonia. — This is a serious complication, and often causes 
death after tracheotomy and intubation. It is ushered in by a rise of 
temperature, increased cyanosis (in laryngeal cases), change of the 



DIPHTHERIA 487 

respiration-pulse ratio from normal 1.4 to 1.3. At first the physical 
sio-ns are those of diffuse bronchitis, later of consolidation over several 
areas. 

Prophylaxis. — The following rules should be observed in preventing 
the spread of diphtheria. (Abstracted from the Rules of the Health 
Department, City of New York.) 

1. No one but the attendant and the physician should be permitted 
to enter the sick chamber. 

2. The discharge from the nose and mouth should be received on 
cloths provided for the purpose, and immersed for two or three hours in 
a solution composed of six ounces of carbolic acid dissolved in one to 
two gallons of hot water, and then boiled in soap-suds for one hour. 
All bed and personal clothing used about the patient should be similarly 
treated inside the sick-room. 

3. The hands of the attendant and the physician should be washed 
in the same carbolic acid solution, and washed in soap-suds after making 
applications or handling the patient, and before eating. 

4. Surfaces soiled by discharges should at once be flooded with carbolic 
acid solution. 

5. Table utensils used by the patient should be kept in the sick-room, 
for his special use, and should be washed in carbolic acid solution and 
then in hot soap-suds. The vessel containing the soap-suds should then 
be washed in the carbolic acid solution. 

6. The sick-room should be aired two or three times daily, and swept 
frequently after scattering sawdust, wet tea-leaves, etc., on the floor to 
prevent the dust from rising. The furniture and the woodwork should 
be wiped with damp cloths. The sweepings should be burned, and the 
cloths soaked in the carbolic acid solution. 

7. All unnecessary articles of furniture, pictures, draperies, clothing, 
etc., should be removed from the room as soon as the nature of the 
malady is recognized. 

8. When the patient has recovered, he should receive a hot soap-suds 
bath, including his hair; clean clothes should be put on, and he should 
be removed from the sick-room. He should be kept in quarantine as 
long as cultures of the diphtheria germ can be obtained from his 
throat. 

In addition to the rules given in regard to the patient and the sick- 
room, the physician and the nurses should protect their clothing by 
wearing long gowns, which should be kept just outside the patient's 
room. 

9. They should also be given immunizing doses of antitoxin. 

10. The room should be scrubbed with bichloride of mercury solution, 
1 to 1000, all over, the woodwork repainted or varnished, the walls cleaned 
and repapered, and the furniture sterilized with formaldehyde vapor. 
In the case of upholstered furniture, disinfection can be more thoroughly 
done by steam. 

11. The periodical inspection of public schools by a corps of physicians 
will do much toward limiting the spread of the disease. 



488 DISEASES OF THE LARYNX 

Immunization by Antitoxin. — An immunizing dose of antitoxin 
ranges from 100 to 500 units, according to the age of the patient and the 
length of time immunity is desired. In an average case 100 units will be 
effective for ten davs, while 500 units will be so for twentv-eiffht davs. 

Treatment of Diphtheria. — The treatment may be divided into (1) 
local, (2) general, and (3) measures for the relief of the suffocation. 

Local Treatment. — This consists in the use of an antiseptic solution, 
such as boracic acid, chloride of sodium, etc., at a temperature of 110°, 
with a fountain syringe. The patient should be wrapped tightly in a 
sheet fixed with safety pins. He should be placed upon his side and the 
glass or hard rubber nozzle of the syringe applied to one nostril, the fluid 
flowing out at the other, until it comes forth clean. The patient's mouth 
should be held open with a spool or a mouth gag, to prevent swallowing, 
as this act might force the solution into the middle ear and cause infec- 
tion and mastoiditis. The pharynx should be treated in a similar man- 
ner. If it is desirable to combat pain and swelling, the temperature of 
the solution should be about 130°. The irrigations may be repeated at 
intervals of six hours. 

General Treatment. — The general treatment of diphtheria consists in 
the administration of stimulants to overcome the depression, the weak 
action of the heart, the irregular pulse, and the septic condition. Alcohol 
in the form of whisky or brandy is the best for this purpose, and should 
be given to an infant in 10 to 15 drop doses, well diluted with water, 
three or four times a day. A child of three or four years may be given 
an ounce in twenty-four hours. In septic cases much more can and 
should be given. Strychnine is the second best stimulant. Dose, child 
one year old, y^- grain every two or three hours. Child three to four 
years old, T Y grain every two or three hours. 

Sedatives should be given to relieve restlessness, cough, and spasm 
(second stage) in laryngeal cases. Morphine may be given in -^ to yV gr. 
doses. Emetics may be given to overcome spasms and to remove mucus 
in laryngeal cases. 

Antitoxin in Diphtheria. — The value of antitoxin is shown by a compari- 
son of the following tables: 

Table I. — By Briggs and Guerard 

Treated with Antitoxin 



Deaths Per cent. 

0-2 years 1494 469 31 . 4 

2-5 years 3678 762 20 . 7 

5-10 years 3184 473 14.8 

Over 10 years 1444 99 6.0 

Table II. — By Babinski 

Not treated with Antitoxin 

A g es Per cent. 

0-2 years 633 

2-4 years 52 . 8 

4-6 years 37 9 

6-10 years „ 24.6 

10-15 years 14.6 



DIPHTHERIA 489 

The advantages of the antitoxin over the other methods of treatment 
at the various ages is strikingly shown by a comparison of the foregoing 
tables, and needs no further comment. 

Antitoxin in laryngeal cases is valuable in two ways, namely: (a) It 
prevents many cases coming to the operative stage, and (b) it affects 
favorably the intubated and tracheotomized cases. Statistics show that 
it affects the intubated cases more favorably than it does those upon 
which tracheotomy has been performed. 

Antitoxin seems to increase paralysis rather than to decrease it. This 
is perhaps explained by the fact that cases treated with antitoxin live 
longer, and thus give more time for the paralysis to develop. Many 
more severe cases survive. 

Injections of antitoxin often produce a transient albuminuria. 

Dosage and Clinical Administration of Antitoxin. — The following 
dosage is recommended : (a) 2000 to 3000 units in ordinary diphtheria 
to a child over one year old ; (b) 3000 to 5000 units in severe laryngeal 
cases of any age; (c) 1500 to 2000 units to an ordinary case in a child 
under one year old. 

Repeat the dose in twelve hours, or less, if the symptoms are increasing, 
and in eighteen to twenty-four hours if there is no decided improve- 
ment. 

A third dose may be given, if needed, in twenty-four hours. 

An ordinary sterilized hypodermic syringe holding 5 c.c. is suitable 
for making the injections. The skin should be cleansed with an anti- 
septic solution. 

Place of Injection. — The skin of the thigh, the posterior axillary line of 
the chest, or the abdomen are favorable locations. 

Effects of Antitoxin on the Pseudomembrane. — In a few hours after the 
injection the pseudomembrane becomes blanched, the dirty color less 
marked, and the membrane more granular and swollen. Later it becomes 
loosened around its edges, rolls up, and detaches itself spontaneously 
or after irrigation. If the membrane returns repeat the dose of antitoxin 
at once. 

Effects on the Temperature. — In pure or simple diphtheria the tempera- 
ture rapidly returns to the normal, whereas in the mixed cases it comes 
down more slowly. If the temperature does not fall in the regular way, 
a second injection is indicated, provided the temperature cannot be 
accounted for by some complication. 

Indications for Antitoxin. — 1. If it is suspected that the child has a 
mild pharyngeal, nasal, buccal, conjunctival, or cutaneous case, give 
antitoxin if he is over one year of age and there is a distinct history of 
exposure. 

2. If a laryngeal case is suspected, give antitoxin at once, and make 
microscopic and cultural examinations afterward. 

3. In all catarrhal cases antitoxin must be given. 

4. In pseudodiphtheria, with repeated negative findings as regards 
the Klebs-Loeffler bacilli, antitoxin need not be given. If in doubt, 
however, give it. 



490 



DISEASES OF THE LARYNX 



Surgical Treatment. — Tracheotomy. — This operation is not now in 
vo£ue, relatively, as it was in former rears. Intubation is usually elected 
in its stead, as it is a safer and surer means of tiding the patient oyer 
the suffocative period. Nevertheless, there are still cases in which 
tracheotomy is indicated. 

The indications for tracheotomy are: (a) When intubation tubes are 
not available, or if, for any reason, their use is not understood (Xorthrup); 



Fig. 304 



Fig. 305 





Tracheotomy tube. 

(b) in excessive edema of the larynx, 
where the intubation tube does not 
give relief: (c) when the membrane 
is in the lower tracheal tract, though 
these cases are favorable for tra- 
cheotomy. 

The method of performing trache- 
otomy now in use is known as the 
high operation, in contradistinction 
to tracheotome inferieure, as first 
practised by Trousseau. In the low 
position of Trousseau, the blood- 
vessels passing over the field of 
operation render the operation 
difficult. 

High tracheotomy is preferable. 
It should be done under antiseptic 

precautions, although this is not always practicable, on account of the 

urgency for immediate relief. 

Steps. — (a) The cricoid cartilage should be located with the index 

finger of the left hand, while the larynx is held firmly but lightly between 

the thumb and the second finger. 

(6) The skin and the subcutaneous tissue should now be incised, 

beginning with the location of the tip of the index finger, carrying it 

downward in the median line \ inch to 1 inch (Fig. 304). 

(c) With the tip of the index finger in the superior angle of the wound, 

the bistoury should be passed under it into the trachea and the incision 



The line of incision in upper tracheotomy 
preparatory to laryngeal fissure or laryngec- 
tomy. 



TRACHEOTOMY 



491 



carried downward in the median line far enough to admit the ringer into 
the wound. With the finger thus placed blood cannot enter the trachea. 
A still better practice is first to check all bleeding with artery forceps or 
ligatures, and then open the trachea. If suffocation is imminent, the 
first method may be adopted. 

(d) The cannula (Fig. 305) should be next introduced as the finger is 
gradually withdrawn. If necessary, the dilator and the retractors may 
be used. 

(e) The cannula should now be secured in its position by pieces of 
tape passed around the neck. 

(f) If the suffocation is not relieved at once, there is either pseudo- 
membrane still lower down in the trachea — perhaps a detached piece 
over the orifice of the cannula — or the cannula has become filled with 
mucus and shreds of pseudomembrane. In this event, the inner cannula 
should be removed and cleared of mucus, etc. 

(g) If the removal of the inner cannula does not relieve the suffocation, 
there is probably membrane low down in the trachea. 

Fig. 306 




O'Dwyer's intubation instruments. 



Mishaps or accidents which may attend the operation are: (a) 
Failure to open into the trachea, especially in very fat children; (b) 
hemorrhage when the incision is carried to either side or too far down- 
ward; (c) an irregular or too small incision, making the introduction of 
the cannula difficult; (d) secondary hemorrhage; (e) asphyxiation from 
dislodged membrane; (f) a too greatly retracted head, thus flattening 
the trachea and causing stenosis. 

After-effects of tracheotomy may be summarized as follows: (a) Dis- 
appearance of the cyanosis and suffocation; (6) sleep; (c) coughing 
with expulsion of pieces of membrane and mucus through the cannula; 
(d) slight fever of two to three days' duration. 

Complications which may arise are: (a) Infection of the tracheal 
wound, the bronchi, and the lungs; (b) ulceration of the trachea at the 
tip of the cannula; (c) erysipelas of the wound; (d) and most important 
of all, bronchopneumonia from the second to the seventh day after the 
operation. When this occurs the prognosis is grave. 



492 



DISEASES OF THE LARYNX 



After-treatment consists in: (a) The removal of the inner cannula 
everv two or three hours for cleansing; (b) the external cannula should 
be removed and cleaned every twenty-four hours, the child being placed 
flat on his back, as in the operation — the wound should be cleansed 
each time the external cannula is removed; (c) under antitoxin it is not 
probable that the cannula will need to be worn after the third day, 
whereas under the older methods of treatment it was usually worn a 
week or more. 



Fig. 307 




Index finger of the left hand holding the epiglottis against the base of the tongue 
preparatory to intubation. (After Shurley.) 



The author recently removed the cannula from a child who had worn 
it for four years. It was necessary first to dilate the glottis which curved 
Heryng bougies introduced through the tracheal opening. After a few 
treatments laryngeal respiration was sufficiently restored and the tube 
was removed. An attempt was afterward made to close the tracheal 
wound, but the anterior wall of the cartilaginous rings of the trachea 
had disappeared from pressure necrosis. The skin, when brought over 
the wound, acted as a valve closing the trachea, and asphyxia resulted. 

Intubation. — To O'Dwyer is due the credit of first practising intuba- 
tion upon his patients. The tubes used at first were straight and easily 
expelled. The tubes were gradually improved and their retention more 
sure (Fig. 306). At about this time Dr. F. E. Waxam successfully 



INTUBATION 



493 



intubated a patient in private practice. Dr. O'Dwyer was greatly 
encouraged by Dr. Waxham's success, and improvement in the tubes 
and instruments for their introduction and removal rapidly followed, 
and, though there was much opposition, intubation became one of the 
recognized therapeutic measures in stenosis from laryngeal diphtheria 
and immortalized O'Dwyer's name. 

The introduction of antitoxin has very greatly reduced the necessity 
for intubation, though there are still many cases in which it is indicated. 

Fig. 308 




The tube passing through the chink of the glottis, the index finger still holding the epiglottis 
against the base of the tongue. A stout loop of thread is attached to the tube to provide for its 
speedy removal in case suffocative symptoms follow its introduction, and in case it is accidentally 
engaged in the esophagus. 

Indications for Intubation. — (a) Great tracheal stenosis, as shown 
by much retracted supraclavicular and epigastric areas, necessitates 
the immediate resort to intubation, even though antitoxin has been 
given and sufficient time has not elapsed for its favorable influence. If 
milder suffocative symptoms are present, and antitoxin has been given, 
intubation may be delayed pending the results of the antitoxin. Since 
the use of antitoxin not one-half as many cases come to operation as 
formerly, (b) If not within easy call, the physician may intubate without 
waiting for marked suffocative symptoms. 

Technique of Intubation. — The child is prepared for intubation by 
wrapping it in * sheet or a blanket from shoulders downward. The 



494 



DISEASES OF THE LARYNX 



sheet should be secured with strong safety pins, so as to bind the arms 
and legs of the child. This being done, the nurse should sit upright in a 
chair with the child upon her lap, his head resting against her left breast. 
His legs should be secured between hers, and her right hand should grasp 
his left, and her left hand his right. The assistant should stand behind 
the nurse and hold the child's head between his hands, as though 
suspending the child from the parietal walls of his cranium. A tube 
(Fig. 309) of proper size, threaded with silk through its eyelet, should be 
in readiness. The operator should stand or sit in front of the child, 



Ftg. 309 




The tube in position in the larynx. The loop of thread is still attached, as the tube may have 
to be removed by the nurse to relieve impending suffocative symptoms. 



introduce the mouth gag, turn it over to the assistant, who holds it between 
his hand and the patient's left cheek while the operator introduces the 
index finger of his left hand and hooks it over the epiglottis (Figs. 307 
and 308). Then, after crowding his finger as far to the left as possible, 
the intubation tube, on the introducer, is carried into the mouth, imme- 
diately over the centre of the posterior portion of the tongue, the handle 
of the introducer being on the chest of the child. As the tip of the tube 
passes back of the epiglottis under the finger of the operator, the handle 
should be gradually elevated, until the tip of the tube is directly over the 
chink of the glottis, when it should be suddenly lowered, thus passing 



INTUBATION 



495 



the tube into the box of the larynx, and on downward into the glottis 
and the trachea. The tip of the finger then engages the rim at the 
head of the tube (Fig. 310), the introducer is loosened and removed, 
and with a gentle pressure the tube is firmly pushed deep into the larynx 
and the trachea. If after waiting twenty to thirty minutes the child 
tolerates the tube, the loop of string should be cut (Figs. 309, 310, and 
311), the index finger reintroduced against the head of the tube, and the 
string removed. For obvious reasons the child should be kept wrapped 
until the string is removed. Fig. 312 shows a false entry of the tube into 
the esophagus, because the handle of the introducer was not sufficiently 
elevated before the tube was dropped into the laryngeal box. 

Fig. 310 




The removal of tlie loop of thread, the index finger of the left hand being placed against the 
head of the tube to prevent its displacement. 



Intubation may also be performed in the dorsal position, the same 
relative positions and steps being observed as in the upright position. 

Extubation or the Removal of the Tube. — The removal of the tube 
may be done by observing the same precautions as are used in intubation, 
the index finger of the left hand guiding the extractor to the opening 
in the tube (Fig. 313). Another method now occasionally used is to 
leave the silk string attached, looping it o^ver the left ear and securing it 
to the cheek -with adhesive plaster. The removal of the tube is thereby 



496 



DISEASES OF THE LARYNX 



rendered quite easy. It is also easy for the child to remove it, hence this 
is a serious objection to the method. One grain of Dover's powder, oi 
Yg to ^2 g r - of morphine, may be given a few minutes before extubation, 
to prevent spasm and reintubation for its relief. 

When to Remove the Tube. — Under antitoxin treatment the tube may 
ordinarily, in a child over two years of age, be removed in from three to 
five days. Should the tube become obstructed, it should be immediately 
removed. 

Fig. 311 




The tube in position after the withdrawal of the thread. 

Complications and Difficulties. — (a) If the finger of the operator is 
short and stubby, it may be difficult to introduce the tube beside and 
beneath it. (b) The tube may make a false passage through the ventricles 
of the larynx, (c) The prolonged efforts of an awkward or inexperienced 
operator may cause suffocative symptoms, (d) Transient spasm of the 
glottis may cause temporary deiay in introducing the tube, (e) The 
narrowest point through which the tube must pass is the cricoid ring, 
and edema or swelling at this point may give rise to some difficulty in 
introducing it. A smaller one may be passed with slight force. The 
action of the tube in being expelled in this condition has'been aptly said 
to "creep back like an oiled cork in a bottle/' (/) Prolonged retention 
of the tube may be necessary on account of the persistence of the 
pseudomembrane, ulcerations about the cricoid cartilages, traumatisms, 



INTUBATION 



497 



cicatricial contractions, edema, abductor paralysis, or exuberant granula- 
tions, (g) More rarely, the tube may be swallowed (no danger from it). 
(h) The tube may become obstructed by the thread or catgut being aspir- 
ated into it and swollen by the secretions; even food may obstruct it. 

The Feeding of Intubated Children. — Most cases take liquid food 
very well when in the upright position, although some take it with pain 
and cough. If the upright position is not practical, Casselberry's posi- 
tion may be resorted to. It consists in placing the patient on his back with 



Fig. 312 




Making a false passage into the esophagus on account of lowering the handle of the obturator. 
The tip of the tube should be introduced by the side of the finger tip, and the handle of the obturator 
elevated until the tube stands perpendicularly, and then passed directly downward through the 
chink of the glottis 



a pillow beneath the shoulders, his head bent downward and backward 
at an angle of 45 degrees, the legs being elevated (Fig. 314). Liquid or 
semisolid food may be given in this position. The child should be allowed 
to swallow several times before assuming the upright position, to remove 
the food from the epipharynx. Hillis places the patient upon his stomach, 
as shown in Fig. 315. Gavage may be resorted to if the pharynx and 
the larynx are not too swollen and painful. The tube should be intro- 
duced through the nose and rapidly passed into the esophagus. Food 
being poured into the funnel passes into the esophagus and the stomach. 
32 



Fig. 313 




Introduction of the obturator for the removal of the tube. The finger is first introduced 
lift the epiglottis and to guide the tip of the obturator into the intubation tube. 

Fig. 314 



mi^r 



/ 




Feeding an intubated child with a nursing bottle. Casselberry's position. The shoulders are 
raised to allow the head to assume a lower position than the shoulders. 

(498) 



INTUBATION 



499 



^Yhen removing the tube, pinch it to prevent the liquid passing into the 
larvnx as it comes out. 



Fig. 315 




Feeding an intubated child through a rubber tube by suction. 



Rectal alimentation may be resorted to if feeding by either of the 
foregoing methods is not practicable. 



CHAPTEE XXVI 

PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMITIES 

PROLAPSE OF THE VENTRICLES. STENOSIS 

SUBGLOTTIC STENOSIS 

According to Chiari, the verrucous form of pachydermia is identical 
with the papilloma of the laryngologist, and has no relation to the diffuse 
form. Diffuse pachydermia may be primary, or it may be secondary 
to some other affection of the larynx, such as tubercle or syphilis. In 
Chiari 's experience typical pachydermia is a very rare disease. He 
describes the following forms: 

1. The most frequent and mildest form is a thickening and loosening 
of the epithelium of the interarytenoid fold and the vocal cords, such as 
frequently occurs in chronic catarrh. The treatment is the same as 
for chronic catarrhal laryngitis, and consists of inhalations, insufflations, 
applications by means of a brush, and cauterization. The best applica- 
tions are lactic acid and iodine. The nitrate of silver is apt to cause 
increased thickening. Small singer's nodules may disappear under the 
influence of rest and the application of the nitrate of silver in solution 
or in the solid stick. If they are of considerable size, forceps should be 
used to remove them. 

2. The typical form of pachydermia laryngis (chorditis nodosa), as it 
affects chiefly the vocal processes, calls for a plan of treatment varying 
according to the circumstances of the case, authors differing greatly 
in their opinions. Some recommend purely expectant treatment and 
avoidance of tobacco, strong drinks, and the abuse of the voice; others 
recommend the internal administration of the iodide of potassium, 
which, though occasionally of some benefit, may also at times produce 
general impairment of health. Chiari recommends the use of elec- 
trolysis, as employed by Moll, of Arheim, a current of from 10 to 12 
milliamperes being used for from three to five minutes at a time. He 
considers it the best means of preventing recurrence, though good 
results have also followed operative procedures. 

3. Large genuine pachydermia growths in the interarytenoid space 
interfere very materially with the voice. Unfortunately, treatment by 
means of cutting forceps, hot or cold snares, etc., do not guarantee 
freedom from recurrence. 

4. The last group includes those circumscribed thickenings, out- 
growths, or nodules which accompany tuberculosis, syphilis, chronic 
perichondritis, and perhaps also lupus, which have been referred to as 
secondary or " accessory" pachydermia. The prognosis depends on 
their etiology, as also does the treatment, the latter varying according 

(500) 



MALFORMATIONS AND DEFORMITIES OF THE LARYNX 501 

to the nature of the most distressing symptoms. Naturally the syphilitic 
form is much more favorable than the tuberculous, though not infre- 
quently it resists specific remedies. Operative treatment of the same kind 
as for the typical primary form is called for in suitable cases; that is, if 
the general health is good and the respiration or voice is not seriously 
interfered with by the local disease. The method of treatment which is 
most highly recommended is the use of electrolysis by means of a bipolar 
instrument with a current of from 10 to 15 ma. This causes no reaction, 
and seems to protect against recurrence better than any other treatment. 
There is no doubt that pachydermia laryngis, whether in the simplest 
form in the interarytenoid space or in the typical form on the processus 
vocalis, is only a symptom of chronic catarrh, and is not to be looked 
upon as a disease itself. 



MALFORMATIONS AND DEFORMITIES OF THE LARYNX 

Malformations of the larynx may be either congenital or acquired. 
But little is known concerning the true cause of congenital malformations, 
only that some paternal disease or taint acts as a predisposing factor. 
Acquired deformities are the result of postnatal disease. 

Malformations of congenital origin are often associated with arrested 
development of the genitalia. The lungs, the bronchi, and the trachea 
have the same embryological origin (the foregUt) as the larynx, hence 
in malformations of the larynx there is also a similar defect in these 
organs. In monstrosities having no larynx the lungs are also absent. 
If the larynx is diminutive, the lungs are likewise affected. Of the other 
congenital deformities, webs or bands across the glottis are a common 
form. The webs usually connect the vocal cords at the anterior commis- 
sure, though they are sometimes between the ventricular bands. They 
are of a pale color, but may be differentiated from the vocal cords by 
their position. They may be either fragile or resilient. The perforated 
diaphragm variety is rare, and is associated with poorly developed 
lungs. Another form of congenital malformation consists of clefts in the 
interarytenoid space extending to the palate and the cricoid cartilage. 
The epiglottis is often deformed by arrested development, the small 
V-shaped epiglottis of childhood being a common variety. A very small 
larynx and total absence of this organ have been reported. 

Hypertrophy or hyperplasia at the anterior commissure has been 
mentioned as being of congenital origin. 

Laryngocele (dilatation of pouches) is due to congenital malformation 
and failure of union in portions of the thyroid cartilage. It is rare in 
man, though common in the lower animals. 

In acquired malformations, erosions from syphilis, tuberculosis, etc., 
may result in the partial destruction of the framework of the larynx, and 
the epiglottis is also often thus partially destroyed. 

Acquired stenosis (see also Stenosis of the Larynx) may follow trau- 
matism or constitutional causes such as syphilis. These cases are serious 



502 DISEASES OF THE LARYNX 

on account of the edema and the dyspnea. Tracheotomy or intubation 
may become necessary. Redundant granulations following the pro- 
longed use of the tracheotomy tube caused laryngeal stenosis in one of 
my cases. The child had been tracheotomized four years before he 
came under my care, and upon examination I found him unable to breathe 
through his larynx. The larynx was opened by bougies passed upward 
through the tracheal wound and through the glottis. This procedure 
was performed under general anesthesia. 

Hypertrophies or growths, usually of a papillomatous nature, form at 
the anterior commissure in either the single or the multiple variety. 
Microscopically they appear as local hypertrophies of the mucous mem- 
brane, having a stratified epithelial covering, enclosing a core of connec- 
tive tissue with some bloodvessels and a glandular substance near the 
base. Indeed, they are but elevations of the normal tissue. This seems 
to distinguish them from true papilloma. Though these papillomatous 
elevations of the mucous membrane are congenital, mouth-breathing, 
according to Lennox Browne, tends to perpetuate them. 



PROLAPSE OF THE VENTRICLE OF MORGAGNI 

Watson Williams claims that there can be no prolapse of the ventricles, 
but that which appears to be a prolapse is, in fact, an infiltration of the 
tissues. This is apparently supported by the fact that nearly all reported 
cases have been either syphilitic or tuberculous. On the other hand, the 
tumor-like mass is quite soft to probe pressure, and a number of observers 
have reported successful, though fugitive, replacement of the pouching 
membrane. 

The presence of this condition should arouse suspicion of either syphilis 
or tuberculosis. The treatment by local applications is useless. Re- 
placement, followed by cauterizations to excite inflammatory reaction, 
offers some hope of permanent cure. Extirpation of the mass with 
cutting forceps, or by thyrotomy, may be resorted to if simpler measures 
fail. Antisyphilitic remedies should first be tried, however, before surgi- 
cal interference is attempted, unless it becomes necessary to perform 
tracheotomy to relieve suffocative symptoms. 



STENOSIS OF THE LARYNX (MALFORMATION OF THE LARYNX) 

Stenosis of the larynx properly comes under malformations, but its 
importance merits separate treatment; hence, the various types of stenosis 
are included in this section, regardless of their relationship to malforma- 
tions. Stenosis arising from constitutional disorders, as syphilis, tuber- 
culosis, and leprosy, each have their peculiarities. 

Syphilitic Stenosis. — There are three prominent conditions arising 
in the course of syphilitic laryngitis which may cause laryngeal stenosis, 
namely: 



STENOSIS OF THE LARYNX 



503 



(a) Chronic edema. 

(b) Cicatricial contraction or webs. 

(c) Hyperplastic or papillary growths. 

(a) Chronic Edema. — Chronic edema is commonly present in syphilitic 
laryngitis, though it does not always seriously occlude the glottis. Never- 
theless, it presents favorable conditions for the supervention of an acute 
process, which may produce serious stenosis. This is especially true 
in children who inherit a syphilitic taint. Such children are predisposed 
to acute edema, which gives rise to symptoms quite like those found in 
croup. Fortunately the infantile cases respond quickly to antisyphilitic 
remedies. In adults, as well as in 

children, the treatment consists in FlG - 316 

the administration of the iodide of 

potash or iodonucleoid, which often 

reduces the local edema in a short 

time. 

It should be stated that it is the 
tertiary stage of syphilis that results 
in stenosis, hence the treatment should 
be conducted accordingly. 

(b) Webs and Cicatricial Contraction. 
— Webs and cicatricial contraction 
are the most common manifestations 
of syphilitic laryngitis. The webs 
vary in color and thickness. They 
are usually pale, and may be indis- 
tinguishable from the cords over which 
they extend. The vocal cords and 
the ventricular bands are usually 
bound together, and the web often 
extends across the chink of the glot- 
tis, especially at the anterior portion (Fig. 316). Lennox Browne cites 
a case in which the epiglottis was bound down by cicatricial adhe- 
sions. 

The voice is hoarse or restricted in its register, while the breathing is 
dyspneic. The degree of the dyspnea depends upon the amount of 
edema and fixation of the cartilages, as well as upon the overlying web 
or cicatricial tissue. When a patient gives a history of recurrent attacks 
of dyspnea extending over several years, it is presumptive evidence 
that he is suffering from syphilis of the larynx. A spasmodic cough, 
not unlike that in pertussis, is usually present. Pain is not uncommon. 
There may be an admixture of syphilis and tuberculosis, which may 
somewhat obscure the diagnosis. 

(c) Hyperplastic or Papillary Growths.— These usually form near the 
anterior commissure of the glottis, and they may be either single or 
multiple. The treatment should be antisyphilitic and expectant. If 
the growths produce stenosis, they should be removed with laryngeal 
forceps, the snare, or by laryngofissure. 




a, cicatricial web across the anterior com- 
missure of the vocal cords. 



504 



DISEASES OF THE LARYNX 



Tuberculous Stenosis. — Tuberculosis of the larynx does not often 
close the glottis by cicatricial contraction, as in syphilis. This is explained 
by the slight reparative effort following tuberculous ulceration. It may 
produce stenosis by the excessive infiltration of the arytenoid carti- 
lages, which may overhang the glottis and occlude the respiratory pas- 
sage. Tuberculous perichondritis and chondritis may result in fixation 
of the arytenoids, and thus prevent abduction of the vocal cords. The 
lumen of the glottis is thereby rendered very narrow, and distressing 
dyspnea results. 

Lupous Stenosis of the Larynx. — Lupus of the larynx is characterized 
by a cicatricial contraction and matting together of the parts. Lupus 
runs a much more chronic course than active tuberculosis of the larynx, 
hence the greater changes. Virchow says that the arytenoids are occa- 
sionally surrounded by hard papillary growths in the active stage of 
lupus. The scar tissue in lupus is very unyielding and not readily 
absorbed, even under the pressure of laryngeal tubes. 

Leprous Stenosis. — The stenosis rarely occurs until the patient is in 
the last stages of the disease. In this stage it often becomes so great 
as to necessitate tracheotomy to relieve the distressing dyspnea. 

Ventricular Eversion and Stenosis. — The eversion of the sacculus 
laryngis is scarcely possible as a primary condition. (See Prolapse of 
the Ventricle of Morgagni.) Anatomically it appears to be too firmly 
adherent to the adjacent tissues to permit of its prolapse. There may be 
a disease of the underlying perichondrium of the laryngeal cartilages 
which predisposes to the eversion and the consequent stenosis. Tumors 
and glandular enlargement may also push the sacculus toward the 
median line and cause stenosis. 

Traumatic Stenosis. — Stenosis of the larynx may be due to the inhala- 
tion of hot vapors or to ingestion of corrosive fluids, as carbolic acid. 
It may also be due to a penetrating wound. In a case recently under 
my care the stenosis was due to the use of a 60 per cent, solution of 
carbolic acid as a gargle. The acute edema rendered it necessary to 
perform tracheotomy. The tube had been worn for seventeen months 
when I first saw him, and had excited a hyperplastic nodule just below 
the posterior portion of the cords. The stenosis seemed to be due more 
to hyperplastic nodule than to cicatricial contraction caused by the 
carbolic acid. We may, therefore, include the prolonged use of the 
tracheotomy tube as a cause of laryngeal stenosis. 

Treatment. — The treatment of laryngeal stenosis is both medical 
and surgical. 

Medical Treatment. — (a) In syphilitic edema and infiltration without 
cicatricial contraction, the iodides are indicated. Saline laxatives may 
be given with good results. 

(b) Acute edema supervening upon a preexisting fibrous stenosis 
should be treated by the local application of adrenalin and by free saline 
catharsis. 

(c) The edema of tuberculous laryngitis may be relieved by tonic 
remedies and the cautious administration of mild cathartics. 



STENOSIS OF THE LARYNX 505 

Surgical Treatment. — (a) Webs of syphilitic origin should be broken 
down by systemic dilatation by means of Schroetter's laryngeal tubes 
(Fig. 317). The larynx should be cocainized, the index finger of the 
left hand introduced through the narrowed chink of the glottis. The web 
will thus be stretched and torn. A larger tube should be introduced 
after leaving the first one in place a few minutes. This process should 
be continued three times a week until the stenosis is completely over- 
come. Even then the tubes should be introduced at intervals of a few 
weeks to prevent the reformation of the webs. 

(b) Cicatricial contraction due to syphilis should be overcome in the 
same manner as described in the preceding paragraph, though the 
dilatations will have to be performed more persistently. 

(c) Hyperplastic or papillary growths of syphilitic origin do not always 
yield to the iodides, and should, therefore, be removed with laryngeal 
forceps under general or cocaine anesthesia, by either direct or indirect 
method. Occasionally the papillary growths become wedged in the 
chink of the glottis and cause sudden and alarming dyspnea, and 
necessitate an emergency tracheotomy. (See Tracheotomy.) 

(d) Tuberculous chondritis and abscess of the larynx, when causing 
stenosis, should be relieved by the removal of the diseased and dislocated 
cartilage with a laryngeal curette or biting forceps. 

Fig. 317 




Schroetter's laryngeal dilator. 

Tuberculous ankylosis of the arytenoid cartilages, attended by fixation 
of the cords in adduction with severe dyspnea, necessitates tracheotomy 
for the immediate relief of the symptoms, or laryngofissure may be 
necessary at a later time to overcome the ankylosis, or to remove the 
arytenoid cartilages. The abduction of the cords during respiration is 
thus made possible and the distressing dyspnea relieved. 

(e) Cicatricial stenosis of lupus should be treated by dilatation with 
Schroetter's tubes, as described in a preceding paragraph, excepting that 
it may require greater persistence. 

(/) Leprous stenosis should be relieved by tracheotomy if the gravity 
of the suffocative attacks warrant it. 

(g) Ventricular eversion with stenosis, while secondary to some 
diseased process of the underlying perichondrium, should be overcome 
by removing the prolapsed sacculus membrane with a snare under 
cocaine anesthesia. Failing in this, tracheotomy may be performed, 
and the everted mass removed subsequently by laryngofissure. (See 
Laryngofissure.) 

Traumatic stenosis, whether of chemical or mechanical origin, may 



506 



DISEASES OF THE LARYNX 



often be successfully treated by first performing laryngofissure (see 
Laryngofissure), and then introducing a tracheotomy tube with a rubber 



Fig. 318 




Tracheotomy tube with rubber tube extension for stenosis of the larynx. 
Fig. 319 




Tracheotomy tube with rubber tube extension for stenosis of the larynx. 

tube extending upward from it through the chink of the glottis (Figs 
318 and 319. The rubber tube exerts constant pressure and gradually 



STENOSIS OF THE LARYNX 507 

removes the hyperplastic tissue causing the stenosis, by pressure atrophy. 
Chevalier Jackson recently reported seven cases successfully treated by 
this method. My own case is progressing favorably and promises to be 
entirely successful. The tube should be worn for from four to sixteen 
weeks, and should be removed every two or three days. 

Subglottic Stenosis. — Sajous pointed out that the subglottic space has 
not received the attention which its importance as an inherent portion 
of the larynx warrants. He urges systemic examination of this space 
in all laryngeal cases. The forms of stenosis peculiar to the lower sub- 
glottic region present features of unusual danger and symptoms likely 
to be ascribed to syphilitic disease. Inasmuch as the iodide of potassium 
greatly increases the danger in subglottic stenosis, it should not be 
administered in a case presenting dyspnea as a symptom, unless the 
non-existence of this condition is determined by infralaryngoscopic 
examination, or the causative disease is clearly recognized as being 
independent of the respiratory tract. He advised that preliminary 
tracheotomy be performed when the iodide of potassium is to be 
administered during the existence of advanced subglottic stenosis. 

Massei states that the subglottic space is the most frequent seat of 
syphilis, tuberculosis, tumors, rhinoscleroma, and foreign bodies. Slight 
syphilitic stenosis is frequently curable without local treatment by the 
administration of sublimate injections with or without the iodides. In 
simple inflammatory and neoplastic stenosis, intubation offers the 
best results. He agrees with Sajous that too great dependence is placed 
in general antisyphilitic treatment in severe stenosis, and that such a 
course may be fataL 



CHAPTEE XXVII 

NEUROSES OF THE LARYNX 

NEUROSES OF MOTION 

The classification of J. Solis-Cohen is as follows : 
Neurosis of the Motor Nerves of the Larynx. — The motor neuroses 
are divided into two groups: 

1. Spasms of the larynx, or hyperkinesis, i. e., excessive motion. 

2. Paralysis of the larynx, or akinesis, i. e., absence of motion. 
Spasms of the Larynx. — Spasms of the larynx may be due to irrita- 
tion of the central brain cells, whereby all the intrinsic muscles are 
thrown into violent action, or to irregular nervous impulses sent out from 
the motor centres of the brain, causing incoordination of the laryngeal 
muscles. 

Paralysis of the intrinsic laryngeal muscles may be limited to one 
muscle or to a group of muscles, or it may affect all of them. 

The spasms may be either tonic or clonic. 

Tonic spasms are (a) of central origin; (b) from irritation of the trunk 
of the recurrent laryngeal; and (c) from reflex irritation. 

(a) Tonic Spasms of Central Origin. — In tabes dorsalis, spasm of the 
adductors of the larynx occurs. The clinical picture shows sudden 
dyspnea with loud inspirations, the cords remaining in adduction for a 
variable time. It also occurs in tetanus and hydrophobia. 

(b) Tonic Spasm from Irritation to the Trunk of the Recurrent Laryngeal 
Nerve. — When the injury is transient and slight, the laryngeal spasm is a 
forerunner of paralysis. Aneurysm of the arch of the aorta, cancer of the 
esophagus, pleuritic adhesion of the apex of the right lung, and tumors 
of the mediastinal glands may cause the irritation. A slight lesion may 
also occur in tabes. 

(c) Tonic Spasms from Reflex Irritation. — These may occur from irrita- 
tion of the larynx, the fauces, and the neighboring parts. In highly sensi- 
tive children irritation in a remote part of the body may cause adduction 
spasms. The latter condition has been described as laryngospasm 
infantum, and is usually due to intestinal irritation, tapeworm, a tight 
prepuce, or constipation. 

Clonic spasms of the laryngeal muscles are always of central origin, 
and they consist of rhythmical inward movements of the cords. The 
condition may last but a few minutes, or it may persist for many months. 
The pillars of the fauces are also often affected in a like manner. 

Both tonic and clonic spasms may be present in the same case, espe- 
cially in the depressors of the epiglottis. The disease most often causing 
(508) 



NEUROSES OF MOTION 509 

clonic spasms of the larynx are syphilis, meningitis, and intracranial 
tumors. 

Clinically, spasm of the larynx may be classified as follows: 

(a) Spasm of the adductor muscles (laryngismus stridulus). 

(b) Spasm of the tensor muscles. 

(c) Spasmodic laryngeal cough or laryngeal chorea. 

(a) Laryngismus Stridulus (Adductor Spasm). — Synonyms. — Spasm of 
the larynx, laryngeal spasm; spasm of the adductors of the vocal cords; 
spasm of the glottis; spasmus glottidis; false croup; child-crowing; 
thymic asthma; asthma rachiticum; Miller's asthma. 

Laryngismus stridulus is a spasmodic act of the intrinsic muscles of 
the larynx accompanied by stridor. It is a neurosis, and is not necessarily 
associated with laryngeal disease. It is not a disease, but a symptom. 
While it is not a disease, it is a symptom causing great alarm. It is often 
associated with laryngeal or tracheal diseases, though it may be a reflex 
phenomenon from irritation in either contiguous or remote organs. It is 
sometimes a symptom of acute laryngitis, pseudomembranous croup, 
and diphtheritic croup, especially in children. It may also occur in non- 
inflammatory diseases of the larynx. It is common in children, but rather 
rare in adults. It is sometimes associated with intestinal disorders, 
as indigestion, worms, and constipation. Uterine disorders and sexual 
excesses have been known to produce it. Disorders of the contiguous 
organs, as the lingual tonsils, the teeth (dentition), elongated uvula, 
and inflamed tonsils, sometimes excite the spasm. Irritation of the 
fauces with a brush, or a foreign body in the pharynx, sometimes causes 
the symptom. Cases have been reported in which the pressure from 
an enlarged thymus gland caused laryngismus stridulus. Cerebral irri- 
tation, caries of the vertebras, and rickets are known causes. Laryn- 
gismus stridulus appears in the laryngeal crises of tabes. 

Treatment. — The treatment consists in relieving the source of the 
irritation rather than in applications to the larynx. For the immediate 
relief from the suffocative spasm, the application of cold water to the 
chest or hot water to the nape of the neck should be made. If suffocation 
seems imminent and the lower jaw is relaxed, seize the tongue between 
the thumb and the forefinger and exert traction about every three seconds, 
to excite the respiratory centre through the reflex action of the phrenic 
nerve. If the jaw is set, the same result can be accomplished by exerting 
pressure with the fingers under the angles of the jaw. Should these 
measures fail, resort to intubation or tracheotomy. 

(b) Spasm of the Tensor Muscles of the Vocal Cords; Aphonia Spastica; 
Phonatory Spasms. — Spasm of the tensor muscles is essentially a neurosis 
from overuse of the voice. The muscles are fatigued and fail to respond 
to the nervous stimulus sent out from the motor centres of the brain; 
they are tired and irritated by a local accumulation of the toxins from 
faulty metabolism. Writer's and telegrapher's cramp are similar affec- 
tions. 

Symptoms. — Spasm of the tensor muscles is characterized by sudden 
onset at any moment during speech. It may come on at the beginning 



510 DISEASES OF THE LARYNX 

or in the midst of a sentence. I have seen cases in which the speech was 
suddenly almost or entirely lost for some minutes, after which it would 
quickly clear up and remain so for an indefinite period. The patient 
complains of a rough, harsh feeling in the larynx, accompanied by 
the spontaneous flow of a few tears and slight congestion of the con- 
junctivae. A drink of water hastens the cessation of the spasms. The 
cords are tense and approximated in the median line. 

Treatment. — The cases seen by the author have been mild, and occurred 
only at long intervals. They required no special treatment other than 
a few minutes' rest of the. voice and a drink of cold water. 

In severe and oft-recurring spastic aphonia, prolonged rest of the 
voice is necessary. Such cases are usually overtaxed, or are affected 
by a slight general debility, and they should, in addition to prolonged 
rest away from the persons with whom they are daily associated, be given 
tonic or specific remedies to correct the debility or the specific diseases 
with which each is affected. To this end iron, strychnine, arsenic, 
cathartics, iodide of potash, eggs, milk, etc., should be given. 

(c) Spasmodic Laryngeal Cough or Laryngeal Chorea. — This condition 
is quite similar to chorea in other parts of the body, though it is not 
usually associated with it. There are, however, synchronous contrac- 
tions of other respiratory muscles which furnish the blast of air back of 
the cough. The choreic cough occurs at frequent intervals, and is a dry, 
noisy, respiratory explosion resembling the yelp or bark of a dog. It 
occurs most often in females at about the age of puberty, or at the age of 
greatest instability of the nervous system. It rarely occurs during sleep. 
Between the intervals the voice is clear. The vocal cords appear normal, 
and are closely approximated during the attacks. 

Treatment. — The cough is due to an hysterical temperament or to a 
lack of balance of the nervous system at or about the age of puberty, and 
little can be done to improve it. A sea voyage or an outdoor life will add 
tone to the system, and thus tend to check the recurrence of the attacks. 
Tonics and sedatives may also be administered. The child should be 
taken from school and sent to the country, or in some way kept outdoors. 
Fresh air and sunshine will do more for these cases than any other mode 
of treatment. 

NEURALGIA OF THE LARYNX 

True neuralgia is rare, and is characterized by pain without a visible 
cause. Similar pain may be caused by malaria, gout, rheumatism, 
pressure from some tumor or swelling, epipharyngitis, and angina of 
the pharynx. It is obvious, therefore, that the foregoing diseases should 
be excluded before making a diagnosis of neuralgia. 

Treatment. — The treatment of a true neuralgia is successfully accom- 
plished with phenacetin, gr. v to x, every three hours, also with cannabis 
indica, aconite, and morphine, which should be administered until they 
produce their physiological effects. Though cocaine, if sprayed into the 
throat, affords immediate relief, it is not to be recommended because 



LARYNGEAL APOPLEXY 5U 

neuralgic patients easily acquire the cocaine habit. Menthol affords 
relief. Cold or hot applications to the neck also prove grateful to these 
patients. 

If the pain is due to gout, rheumatism, malaria, or pressure of a tumor 
or a gland, treatment appropriate to these conditions should be instituted. 



MOGIPHONIA 

Mogiphonia is characterized by a difficulty in maintaining the tension 
of the vocal cords while singing, or during forced accentuated speaking. 
In ordinary conversation no difficulty is experienced. 

Treatment. — The treatment is rest. Overtaxation being the cause, 
other forms of treatment are not indicated, unless the condition has 
recurred often and at frequent intervals. When this is the case, tonics, 
massage, cathartics, and eliminative treatment should also be used. 



NERVOUS COUGH 

This is a spasmodic, croupy, or even musical laryngeal cough, for 
which no physical cause can usually be assigned. It is peculiar to neurotic 
individuals who present other stigmata of a neurosis. It is a " daytime" 
cough, which subsides entirely during sleep, but returns the following 
morning, often with increased severity. It may be a reflex disturbance 
from a hypersensitive area in the nose, the epipharynx, or the chest, 
hence a careful examination of these parts should be made. The sensi- 
tive areas in the nose and the epipharynx may be located by gentle 
probe pressure without the use of cocaine. In the nose Jacobson's 
tubercle near the anterior end of the middle turbinated body may be 
the seat of the sensitive area. When this is touched with the probe 
it will give rise to the peculiar nervous cough, provided, of course, that 
it is the source of the reflex. Impacted cerumen in the external auditory 
meatus may cause it. The reflex may also have its origin in the gastro- 
intestinal tract. 

Treatment. — As most cases are due to a true neurosis rather than to 
some physical lesion, the treatment must be of a tonic and sedative 
character. Sprays of iced lime water, or menthol in combination with 
camphor, gr. ij to an ounce of liquid petrolatum, etc., may be used to 
relieve the laryngeal irritations. Antispasmodics and sedatives, as 
aconite, cannabis indica, and the bromides, may be given internally to 
allay the spasms and the local irritation. 



LARYNGEAL APOPLEXY 

Synonyms. — Laryngeal vertigo; laryngeal syncope; bronchial syncope; 
complete glottic spasm in the adult, 



512 



DISEASES OF THE LARYNX 



Laryngeal apoplexy is characterized by a transient irritation and 
burning sensation in the lower part of the throat, followed by a fit of 
coughing, dimness of vision, dizziness, and unconsciousness, the patient 
falling to the floor. The face may be either congested or pale. 

The disease is a neurosis affecting the coordination of the respiratory 
centres and the nerves of the larynx. It is rare. The attacks may last 
but a few seconds, when the spasms cease and the mind becomes clear 
again. They may recur at intervals of a few weeks. 

Etiology. — The disease is chiefly found among the well-to-do and those 
leading sedentary lives, though one case is reported as occurring in a 
sailor (Whalan)/ Getchell reported 77 cases ranging in age from seven- 
teen to seventy-seven years. All but four were males. Rheumatism 
and gout are occasionally associated with it. Neurasthenia is a rather 
constant factor. Local inflammatory disease of the bronchi, the pharynx, 
and the larynx is commonly present, and may be an important causative 
agent, Lennox Browne reported 3 cases in which there was varix at 
the base of the tongue. 

Among the exciting causes may be named worry from strenuous 
business or social conditions, and either physical or mental overwork. 
A pinch of snuff or other irritating substance inhaled into the larynx 
and the bronchi may bring on an attack. 

SymptoiiLS. — The face is usually flushed, though it may be pale. 
A deep breath is taken, followed by laryngeal spasm. There may be 
epileptiform convulsions, and the sequence ends in a few moments by 
a return to consciousness. After the attack all signs of the disease dis- 
appear. The disease is clinically like apoplexy with a laryngeal aura 
and laryngeal spasm, the latter being continued long enough to produce 
unconsciousness. Such spasms are likely to occur in neurasthenia and 
in tabes. Other signs of neurasthenia, epilepsy, and tabes should be 
sought for before pronouncing the case one of laryngeal apoplexy. 

Treatment. — The treatment should be addressed to the correction of 
alimentary and hepatic disorders and to the regulation of the excretory 
organs of the body. Tonics and antispasmodics may be given to tone 
and tranquillize the nervous system. Local lesions, if present, should 
receive appropriate treatment. For instance, bronchitis is the most 
common concomitant disease, and possibly has something to do with its 
causation. It should, therefore, be treated by the administration of 
4 grains of iodide of potassium in a glass of water after each meal for 
several weeks or months. By relieving the associated diseases of the 
upper respiratory tract, the laryngeal spasms and the syncope are some- 
times entirelv relieved. 



PARALYSES OF THE INTRINSIC MUSCLES OF THE LARYNX 

It is difficult to make a classification of the paralyses of the laryngeal 
muscles in -such a way as to have it coincide with clinical observation. 
The intrinsic muscles are supplied by branches of the right and the left 



PARALYSIS OF THE INTRINSIC MUSCLES OF THE LARYNX 513 

pneuniogastric or vagus nerves. It will be remembered that these nerves 
have their origin near the median furrow beneath the floor of the fourth 
ventricle. Two motor branches, the superior laryngeal and the recurrent 
or inferior laryngeal, are given off from each vagus to the larynx. The 
superior laryngeal also supplies sensation to the whole laryngeal mucous 
membrane. 

By reference to Fig. 320, it will be seen that the superior laryngeal 
supples only one pair of the intrinsic muscles of the larynx, the crico- 
thyroidei. These muscles are tensors of the vocal cords, hence the wavy 
outline of the cords (Fig. 321) in superior laryngeal paralysis. 

Fig. 320 




Schema of the nerve supply of the intrinsic muscles of the larynx: P, the pneumogastric nerve; 
R, recurrent laryngeal nerve; S.L., superior laryngeal nerve; A.C., arytenoid cartilages; T, thyroid 
cartilage; C, cricoid cartilage; A, interarytenoideus muscle; C.A.P., crico-arytenoideus posticus 
muscle; C.A.L., crico-arytenoideus lateralis muscle; T.A.I., cricothyroidei interni muscles. 



The recurrent or inferior laryngeal nerves supply all the other intrinsic 
muscles of the larynx, namely, the arytenoideus, the crico-arytenoidei 
postici, the crico-arytenoidei laterales, and the internal tensors of the 
vocal cords. 

If the lesion involves all the fibers of the left recurrent laryngeal nerve, 

there is total paralysis of all the muscles of the left side of the larynx 
33 



514 



DISEASES OF THE LARYNX 



Fig. 321 



except the cricothyroideus (external tensor). The same is true of the 
right side (Fig. 321). If the lesion involves only a small branch of the left 
recurrent, one muscle alone may be involved, say the crico-arytenoideus 
lateralis. This muscle is an adductor, hence there would be incom- 
plete adduction of the anterior two-thirds of the vocal cord on the 
left side, while the opposite cord would slightly encroach beyond the 
median line. The adduction of the posterior third is controlled by 
the arytenoideus, hence, this muscle being unaffected, closure in that 
region is complete. Single muscles are rarely affected except in diph- 
theria and other local inflammations of the larynx, and in hysteria. 
It is always a question when a single muscle is affected, excepting one 
of the cricothyroidei, as to whether the lesion is in a nerve twig or in 
the muscle itself. Inflammatory infiltration may inhibit the nerve twig 

supplying a certain muscle, or the infiltra- 
tion may cause a mechanical barrier to the 
proper motion of the muscle. Hysterical 
paralysis is, of course, not a true paralysis. 
Paralysis of involuntary muscles usually 
has its origin in a lesion of the medulla 
oblongata or the spinal cord. Lesions of 
the cerebral cortex, on the other hand, 
cause central paralysis of voluntary motion. 
In making a diagnosis in this class of cases, 
aphasia must be distinctly separated from 
aphonia; the same is true in considering 
the etiology. Kraus, in 1884, demonstrated 
that stimulation of the gyrus prefrontalis 
in the lower animals produced a contrac- 
tion, or muscular movements, of the larynx, 
the pharynx, and the palate. Semon and 
Horsley fully substantiated the findings of Kraus by a long series of 
experiments on the lower animals. 

Irritation of one of the external borders of the restiform bodies pro- 
duces unilateral adduction of the vocal cords. Bulbar lesions usually 
produce unilateral paralysis, but many cases of unilateral paralysis are 
also caused by lesions in the medulla. 

Laryngeal paralyses are seldom brought about by tumors of the 
medulla or the pons. Gottstein thoroughly reviewed this aspect of the 
question, and refers to several cases of glioma and one of aneurysm of 
the basilar artery. A bulbar lesion causing laryngeal paralysis usually 
involves the dorsal motor nucleus of the pneumogastric, which lies near 
the median furrow, and is beneath the floor of the fourth ventricle. 1 In 




Paralysis of the cricothyroidei. 
The only muscles of the larynx sup- 
plied by the superior laryngeal. All 
the other intrinsic muscles of the 
larynx are supplied by the recur- 
rent laryngeal nerves. 



iEdinger, Anatomy of Central Nervous System of Man, English translation from fifth German 
edition, p. 375, says: 

"We have learned, then, two nuclei for the vagus, a ventral one, which from its position (in the 
prolongation of the ventral horn) and from the appearance of its cells (multipolar with axis cylinders 
passing directly into the nerve) is motor; and a dorsal one, which, lying in the prolongation of the 
gray matter of the base of the posterior horn, is also by its structure characterized as sensory." 



PARALYSIS OF THE SUPERIOR LARYNGEAL NERVE 515 

laryngeal paralysis the abductors are usually the first, perhaps the only, 
muscles affected as a result of a central or a peripheral lesion, while in 
hysterical aphonia the adductors are affected. 

Tumors, traumatisms, and other lesions at the base of the skull give 
rise to laryngeal paralysis by implicating the trunks of the pneumo- 
gastrics. It is often difficult to differentiate these conditions from bulbar 
lesions, as they frequently involve the facial, the glossopharyngeal, the 
acusticus, the spinal accessory, also other branches of the pneumogastrics 
besides the laryngeals, depending upon the extent of the lesion. The 
portion of the pneumogastric which lies in the neck (usually the trunk 
and the recurrent laryngeal after it winds around the large vessels in the 
thorax, travelling back along the esophagus to the larynx) is very often 
the seat of the lesion causing the laryngeal paralysis. Among the lesions 
in this locality causing paralysis of the nerves just mentioned are en- 
larged glands, traumatisms due to wounds in operating, goitres, aneu- 
rysms, mediastinal tumors, tumors of the esophagus and the pharynx, 
pleurisy, scoliosis of the cervical vertebra?, tuberculosis of the apices of 
the lungs, and even pericarditis. 

Laryngeal paralysis may be the very first and for a long time the only 
significant indication of an aneurysm of the arch of the aorta. Cften 
no palpable reason for the paralysis can be ascertained, and then recourse 
must be had to a tentative diagnosis of a simple neuritis. The rare 
cases of paralysis of individual muscles must be ascribed to lesions of 
their respective nerve twigs, or to an involvement of the muscular struc- 
ture itself. Paralysis of the abductors is now and then due to traumatism 
by the passage of a bolus of food or cold drinks through the lower pharynx 
into the esophagus, as the location of the muscles is very superficial. 
In paralysis of the pneumogastric nerve due to a bulbar lesion the in- 
volvement of the other nerves readily establishes the diagnosis. How- 
ever, an injury to the base of the skull may simulate a bulbar lesion by 
implicating several nerve trunks in addition to the pneumogastric. 
Jackson, Proust, Senator, and Eisenlohr have reported cases of bilateral 
paralysis as being due to bulbar lesions, though they are comparatively 
rare. There is no authenticated case of paralysis of the adductors 
alone from a central lesion. Occasionally a bulbar lesion produces 
bilateral paralysis, in which instance the abductors alone are usually 
involved; more often the paralysis is unilateral, though not so often 
as when due to other lesions. 



PARALYSIS FROM DISEASE OR INJURY OF THE SUPERIOR 

LARYNGEAL NERVE; PARALYSIS OF THE EXTERNAL 

TENSORS OF THE VOCAL CORDS 

So far the only lesions which have been noted as causing paralysis 
of the cricothyroid muscles are diphtheria, enlarged glands, and inflam- 
mation of the areolar tissue beneath the angle of the jaw. Typhoid 
fever may cause it. Paralysis of these muscles is extremely rare. 



516 DISEASES OF THE LARYNX 

Symptoms. — Anesthesia of the larynx, the phenomenon which was 
described under neurosis of the larynx, is a prominent and significant 
symptom. The anesthesia is explained by the fact that it is the superior 
laryngeal nerve, a branch of the pneumogastric, which is affected. This 
branch supplies the cricothyroid muscles with motor stimulus, and 
the whole of the mucosa with sensation. Whenever, therefore, there is 
anesthesia of the whole mucosa of the larynx, the lesion involves the 
superior laryngeal nerve fibers, either after they leave the pneumogastric 
or higher up in the pneumogastric itself. A low-pitched voice and 
inability to sing high tones is characteristic of this affliction. When the 
thyro-epiglottic and the aryteno-epiglottic muscles are paralyzed, the 
epiglottis stands upright, hence the larynx cannot be closed. Because 
of this and the attending anesthesia, food often finds its way into the 
larynx and upper respiratory tract. No warning is given the patient 
until the food reaches an area below the vocal cords. Hence, pneumonia 
is frequently a serious sequence. Complete bilateral paralysis of the 
cricothyroid muscles is manifested by the peculiar wavy outlines of the 
vocal cords (Fig. 321). According to E. MacKenzie, when this paralysis 
is unilateral the laryngoscope shows one vocal cord on a higher plane 
than the other. 

Diagnosis. — The peculiar wavy outline of the vocal cords and the 
local anesthesia clear up the diagnosis as to the hoarseness and aphonia, 
and distinguish it as a true motor paralysis rather than a neurosis or an 
inflammatory disease. 

Prognosis. — It is very bad if there is complete bilateral paralysis, 
but not so very grave when only one cord is implicated. The patient 
may succumb to inanition or pneumonia. Lobar pneumonia is the 
usual type, and cases have been recorded in which death from this disease 
could only be ascribed to the passage of food or other foreign substance 
into the trachea because of the anesthesia. The prognosis is very bad 
if the recurrent laryngeal nerve is involved at the same time. 

Treatment. — Nourishment by the esophageal tube, galvanism, strych- 
nine, and general tonics are indicated. 



PARALYSES OF THE RECURRENT OR INFERIOR LARYNGEAL 
BRANCH OF THE PNEUMOGASTRIC NERVE 

All the intrinsic muscles of the larynx except the cricothyroidei are 
supplied with motor stimulus by the recurrent laryngeal nerves. The 
crico-arytenoidei postici are abductors of the vocal cords and therefore 
muscles of respiration, in a sense, also, of phonation, as their action is 
necessary to maintain the required equilibrium of the other muscles in 
this act and in modulating the voice. 

The recurrent laryngeal nerve supplies motor stimulus to the following 
muscles: 



PARALYSIS OF BOTH RECURRENT LARYNGEAL NERVES 517 



Recurrent laryngeal 
(inferior laryngeal 
nerve) . 



Crico-arytenoidei laterales (adductor). 

Arytenoideus (adductor) . 

Crico-arytenoidei postici (abductor) . 
. Thyro-arytenoidei interni (relaxors). 
nerve supplies the cricothyroidei (external 



The superior laryngeal 
tensors). 

It is clear, from the above analysis, that the recurrent laryngeal nerve 
is the chief motor supply to the larynx, and that it presides over both 
adduction and abduction of the vocal cords. 
It is obvious, therefore, that when all the fibers FlG - 322 

of the main trunks of the recurrents are 
affected there is total paralysis of both the 
adductor and the abductor muscles of 
the larynx. The only intrinsic muscles of the 
larynx not affected are the external tensors, 
the cricothyroidei, which are supplied by the 
superior laryngeal nerves. These play so 
small a part in the general movements of the 
cords that their action under these circum- 
stances is practically nil. The cords, there- 
fore, assume the so-called cadaveric position 

(Fig. 322). In studying the various paralyses of the recurrent laryn- 
geal I shall first speak of total paralysis, and follow with the partial 
paralyses. I mean by the term partial paralysis, the paralysis of certain 
groups of muscles rather than an incomplete paralysis of part or all of 
the muscles of the larynx. 




Larynx in quiet breathing and 
the cadaveric position. 



COMPLETE PARALYSIS OF BOTH RECURRENT LARYNGEAL 

NERVES 

Etiology. — By reference to Fig. 323, the course and distribution of 
the right and the left recurrent laryngeal branches from the pneumo- 
gastrics is illustrated in diagrammatic form. The left recurrent is given 
off at the level of the transverse portion of the arch of the aorta, and 
passes under it, thence upward in the groove between the trachea and 
the esophagus to the muscles of the larynx. As it reaches the larynx it 
breaks into several twigs, thus supplying motor stimulus to all the in- 
trinsic muscles of the left half of the larynx except the cricothyroid, 
which is supplied by the superior laryngeal. The left recurrent nerve is 
the one most often affected, on account of its relationship to the arch of 
the aorta and the left subclavian artery. Aneurysm of the transverse 
portion of the arch of the aorta causes compression and neuritis of the 
left recurrent laryngeal, and thus inhibits the motor impulses reaching 
the left half of the larynx. Unilateral paralysis results. Occasionally 
the aneurysm is so large as to encroach upon the structures on the 
right side of the chest, and may thus also cause compression and neuritis 
of the right recurrent, in which event the paralysis would be bilateral. 

While the right recurrent laryngeal is not so often involved, it is, 



518 



DISEASES OF THE LARYNX 



nevertheless, so situated with reference to the subclavian artery and the 
apex of the right lung as to be somewhat frequently the source of laryn- 
geal paralysis. The right recurrent nerve is given off on the level with 
the subclavian artery, and curves around the latter as it starts upward 
to the larynx. Aneurysm of the subclavian may therefore compress it 
and cause neuritis and consequent laryngeal paralysis of the intrinsic 
muscles of the right half of the larynx. The right recurrent nerve is in 

close proximity to the apex of the 



Fig. 323 



in- 



right lung, and may become 
volved in pleuritic exudates and 
adhesions in this region, and thus 
cause paralysis of the right half of 
the larynx. 

The mediastinum is frequently 
the seat of malignant or other 
growths which press upon one or 
both of the recurrent nerves. En- 
larged glands of the neck, malig- 
nant tumors of the esophagus, and 
other growths in the neck may 
cause pressure and degeneration of 
one or both pneumogastric nerves, 
and produce unilateral or bilateral 
paralysis of the larynx. Scoliosis, 
goitre, and pericarditis may also 
injure the recurrent nerves. Gum- 
mata are frequently the source of 
the nerve lesion. 

The central lesions which cause 
laryngeal paralysis are in the 
medulla oblongata or the spinal 
cord. The exact location of the 
pneumogastric nuclei seems to be, 
according to Kraus, Semon, and 
Horsley, in the gyrus prefrontalis. Tumors of the medulla and the 
pons rarely cause laryngeal paralysis. Aneurysm of the basilar artery 
is a known cause. Bulbar lesions causing laryngeal paralysis usually 
involve the dorsal motor nucleus of the pneumogastric nerve which 
lies near the median furrow beneath the floor of the fourth ventricle. 

Tumors, traumatisms, and other lesions at the base of the skull give 
rise to laryngeal paralysis by implicating the trunks of the pneumo- 
gastric nerves. It is often difficult to differentiate these from bulbar 
paralysis, as these conditions often involve the facial, the glossopharyn- 
geal, the acusticus, the spinal accessory, or other branches of the 
pneumogastric nerve. 

The nerves and their filaments may be completely atrophied. The 
remains of the neurilemma have been found, but fatty degeneration is 
the most frequent degenerative change. 




Schema showing the relations of the pneu- 
mogastric nerve to the trachea, esophagus, 
and vessels of the thorax. Also the recurrent 
laryngeal and superior laryngeal branches and 
their distribution to the intrinsic muscles of 
the larynx. (See Fig. 320.) 



PARALYSIS OF BOTH RECURRENT LARYNGEAL NERVES 519 

Symptoms. — The symptoms, whether due to lesion of the pneumo- 
gastric trunk or to the recurrent laryngeal nerve, are very much alike. 
The voice is usually weak and husky. The sensibility of the mucous 
membrane is usually unimpaired, unless the lesion of the pneumogastric 
trunk is above the point where the superior laryngeal nerve is given off. 
If both pneumogastric trunks or both recurrent nerves are injured, the 
voice is aphonic, as the cords stand in the cadaveric position. If the 
recurrent nerve on one side only is affected, the vocal cord on that side 
rests in the cadaveric position, while the opposite cord has its normal 
movements. Indeed, it encroaches beyond the median line upon at- 
tempted phonation, while during deep inspiration it is widely separated 
from the opposite cord. In one-sided paralysis the position of the aryte- 
noid cartilages is characteristic; the arytenoid cartilage on the unaffected 
side overlaps the opposite arytenoid, and is either anterior or posterior 
to it. Cough is usually absent, and when present is usually due to an 
irritation of the trachea by the pressure of a tumor in the neck or upper 
mediastinum. The cough is like that in aneurysm of the arch of the aorta. 
I have seen a few cases of aneurysmal cough, and they were dry and 
slightly harsh or brassy. One case in particular was free from cough 
except in public gatherings or other places likely to excite the heart's 
action. Coughing and expectorating are performed with great difficulty 
in bilateral paralysis. 

Dyspnea is absent in unilateral paralysis, but may be present in 
bilateral paralysis in spite of the fact that the cords are separated in 
the "cadaveric" position. In the "cadaveric" position the cords stand 
midway between adduction and complete abduction. They are not as 
widely separated as is usual in inspiration, hence the dyspnea. 

In some cases the paralysis is partial, and the symptoms are, therefore, 
correspondingly modified. 

Sir Felix Semon and Rosenback have shown that the abductor nerve 
fibers degenerate earlier than the adductor nerve fibers, hence the 
abductor muscle (crico-arytenoideus posticus) is paralyzed earlier than 
the adductor (crico-arytenoideus lateralis). This phenomenon is usually 
referred to as "Semon's law." If, therefore, the case is seen early the 
abductors may be paralyzed. If, however, the case is examined at a 
later period, the degeneration will have extended to both the abductor 
and the adductor nerve fibers, and the paralysis will affect both the 
abductor and the adductor muscles. This causes the so-called "cadav- 
eric" position of the vocal cords. 

Diagnosis. — Bilateral paralysis of the abductor nerves during quiet 
respiration bears a slight resemblance to complete paralysis. The act 
of phonation, however, is attended by the adduction or approximation 
of the cords, which readily distinguishes it from the passivity of the 
cadaveric position. 

Prognosis. — In view of the serious nature of the causes which produce 
complete paralysis of one or both recurrent laryngeal nerves, the progno- 
sis is grave. In case it is due to syphilitic gummata or to the pressure 
of enlarged glands, the prognosis under appropriate treatment is good. 



520 DISEASES OF THE LARYNX 

If due to the toxemia of diphtheria or to an acute inflammation, complete 
recovery may occur in a few weeks. 

Treatment. — The treatment depends upon the cause of the paralysis 
and the duration of the symptoms. If enlargement of the thyroid gland 
is the cause, the administration of thyroid extract may diminish the size 
of the tumor and thus relieve the pressure upon the nerve. An operable 
tumor causing pressure upon the trunk of the pneumogastric or the 
recurrent laryngeal nerve should be removed in order to relieve the 
pressure. If the nerve has undergone degenerative changes, improve- 
ment mav be slight or may not result ; if, however, the nerve is still healthy, 
the paralysis may disappear after the operation. In aneurysm of the arch 
of the aorta or of the right subclavian, dependence should be placed in 
the use of iodonucleoid in from 5 to 15 grain doses three times a day. 
Syphilitic gummata may be treated with mercurial inunctions and the 
internal administration of iodonucleoid in doses ranging from 10 to 25 
grains three times a day; or the iodide of potash 10 to 60 grains three 
times a day. The iodonucleoid is as reliable a drug as the iodide of 
potash, and has the advantage of being tolerated by the most sensitive 
stomach. It is free from potash, having a nucleoid base. It is absorbed 
more readily by the blood and rapidly saturates the system with 
iodine, which is the active agent in both the iodide of potash and the 
iodonucleoid. 

Galvanism and faradism combined with external massage over the 
laryngeal region may increase the circulation and nutrition of the 
atrophied muscles. Strychnine is also a valuable remedy, because it 
increases the nerve energy and tone of the muscles. 

If the paralysis is due to diphtheria or one of the exanthemata, consti- 
tutional remedies, as strychnine, iron, and the bitter tonics, should be 
given to build up the waning and depleted cell energy. Eliminative 
remedies, to stimulate the excretory powers of the intestines, the kidneys, 
the liver, and the skin, should be given to clear the toxins from the blood 
and the lymph. 

Tracheotomy may become necessary in a case of severe dyspnea. 

UNILATERAL PARALYSIS OF THE RECURRENT LARYNGEAL 

NERVE 

Etiology.— Unilateral paralysis of one-half of the intrinsic muscles 
of the larynx is quite common, as each nerve traverses a long and un- 
interrupted course before it gives off the terminal twigs to the muscles 
of the larynx. The left recurrent is given off from the pneumogastric 
nerve on a level with the transverse portion of the arch of the aorta around 
which it curves (Fig. 323) and passes upward in the groove between the 
trachea and the esophagus to the larynx. Aneurysm of the transverse 
portion of the arch of the aorta compresses it and causes degenerative 
changes and consequent laryngeal paralysis. Tumors of the medias- 
tinum and of the neck or enlarged glands of the neck may compress 
and injure it. The right recurrent nerve is given off from the right 



LARYNGEAL PARALYSIS 521 

pneumogastric on a level with the right subclavian artery, around which 
it curses in close contact with the apex of the right lung. Aneurysm 
of the right subclavian causes compression and degeneration of the right 
recurrent laryngeal nerve, and paralysis results. Pleuritic inflammation 
and adhesions at the apex of the lung may involve the right recurrent and 
cause laryngeal paralysis upon that side. Malignancy of the esophagus 
or other growth, or inflammatory swelling, may involve either the right 
or left recurrent laryngeal nerve and produce unilateral paralysis. 

Symptoms. — The symptoms include hoarseness or even aphonia at 
the beginning of the paralysis. Later, the unaffected cord compensates 
for the loss of motion on the affected side, and the aphonia or hoarseness 
is improved. Dyspnea is absent. The laryngeal image shows the vocal 
cord on the affected side in the "cadaveric" position, i. e., half-way 
between adduction and abduction, while the unaffected cord performs 
both adduction and abduction without restraint. The epiglottis may 
deviate from the median line. 

Prognosis. — The prognosis depends upon the cause. If due to a 
transient inflammation or exudate, it is good under appropriate treat- 
ment. If due to syphilis, the prognosis is good if the case is properly 
treated. If due to some incurable disease, the prognosis is correspond- 
ingly grave. If dyspnea is present, the prognosis is more grave. 

Treatment. — When practicable, treat the disease causing the paralysis 
as in postdiphtheritic or postexanthematic and syphilitic affections. If 
an incurable disease, as carcinoma or sarcoma of the mediastinum, 
the esophagus, or the larynx, is the cause of the paralysis, treat the 
distressing symptoms as they arise. If the thyroid gland is enlarged, 
give thyroid extract, or perform thyroidectomy if the extract fails. 



LARYNGEAL PARALYSIS FROM LESIONS OF THE MEDULLA AND 
THE NUCLEI OF THE SPINAL ACCESSORY NERVE 

Laryngeal paralysis from disease or injury of the medulla oblongata 
and the nuclei of the accessory portion of the spinal accessory is character- 
ized by paralysis of all the intrinsic muscles of the larynx on the side 
involved, or if only a few filaments are involved there will be paralysis 
of only one or at most two muscles of the larynx. It is still further char- 
acterised by the paralysis of certain muscles, extrinsic to the larynx, 
which are supplied by nerves having their origin in the immediate vicinity 
of the motor nucleus of the pneumogastric. Thus there may be para- 
lysis of the facial, the acusticus, or of the nerves leading to the extremities. 

Pathology. — Laryngeal paralysis due to a central lesion is dependent 
upon the involvement of the spinal accessory roots, from which some of 
the fibers of the pneumogastric nerves arise in the floor of the fourth 
ventricle. There must be a lesion in the medullary or nerve roots supply- 
ing the larynx. Syphilis, locomotor ataxia, progressive bulbar paralysis, 
multiple sclerosis, and tumors of the neck and the brain comprise the 
chief morbid anatomy of central paralysis of the larynx. 



522 



DISEASES OF THE LARYNX 



Diagnosis. — The diagnosis depends on the symptom complex of all 
the nerves involved. There is usually an associated paralysis of the 
nerves supplying the tongue, the palate, and the facial muscles, or of the 
nerves of audition, or of the extremities. Other regions supplied by 
the accessory root may be paralyzed. All the intrinsic muscles of the 
larynx may be paralyzed, or only a part of them, depending on whether 
all or only a few of the fibers from the pneumogastric motor nucleus are 
diseased. 

Prognosis. — The prognosis is nearly always very grave, and even 
when the disease is due to syphilis it should be guarded, though under 
antisyphilitic treatment improvement may be expected. 

Treatment. — The treatment should be varied to meet the symptomatic 
indications. If syphilis is present, the iodonucleoid or the iodide of 
potash should be given in large doses. If a malignant growth is the cause, 
treat the unfavorable symptoms as they arise. If marked dyspnea is 
present from paralysis of the abductors on both sides, either intubation 
or tracheotomy should be performed. 



BILATERAL ABDUCTOR PARALYSIS 

Etiology. — The causes of bilateral abductor paralysis of the vocal 
muscles are syphilis, mediastinal tumors, aneurysm, and enlarged medias- 
tinal lymphatic glands. Neurasthenia is also a cause of the paralysis. 



Fig. 324 




Fig. 


325 


Jf^\ 


lm\ 


n 




y 


^^JF 



Bilateral paralysis of the thyro-arytenoidei 
interni and of the arytenoideus. 



Position of the cords when emitting a high- 
pitched tone and in abductor paralysis. 



Symptoms. — The symptoms have been so admirably given by N. L. 
Wilson in an article read before the American Laryngological, Rhino- 
logical, and Otological Society, in 1900, that I will quote him: 

"The patient gave a remote history of syphilis, and was somewhat 
addicted to alcohol; has had a few attacks of dyspnea, especially at 
night, for the past eight months. Voice only slightly husky, inspiration 
a little noisy, and expiration soundless. Occasionally had headaches. 
Ophthalmoscope showed nothing abnormal. Heart and lungs normal; 



BILATERAL ABDUCTOR PARALYSIS 



523 



urine, acid and clear, specific gravity 1020. There was no albumin or 
sugar. The laryngoscopic examination showed the epiglottis to be 
normal, mucous membrane of the larynx normal, the vocal cords white, 
with a small slit between them during inspiration. The left vocal band 
was immovable in the median line; the right moved slightly." (Fig. 325.) 
The patient was warned of the danger of sudden death from dyspnea, 
but refused to be tracheotomized. Three months later he died suddenly 
from dyspnea. 



Fig. 326 



Fig. 327 



Fig. 328 






Unilateral paralysis of the 
thyro-arytenoidei interni and 
of the arytenoideus. 



Paralysis of the thyro-ary- 
tenoidei interni. 



Bilateral paralysis of the 
arytenoidei. 



Fig. 329 



Fig. 330 



Fig. 331 






Unilateral paralysis of the 
right arytenoideus. 



Paralysis of the adductor 
muscles of the larynx. It 
also shows the position of 
the cords in deep inspiration. 



Paralysis of the adductors 
and arytenoideus. 



Pathology. — When due to syphilis, the disease may affect the abductor 
muscles, the peripheral nerve filaments of the recurrent nerves, the nerve 
trunk, or the medulla. When due to mediastinal tumors, aneurysm, or 
enlarged glands, the recurrent trunk is pressed upon, causing atrophy 
or other degenerative changes in its nerve fibers. When due to neuras- 
thenia, the flow of the nervous impulses through the recurrent nerve 
are inhibited. 

Prognosis. — The cases of paralysis due to neurasthenia generally 
recover, though death may occur. When the paralysis is due to other 



524 DISEASES OF THE LARYNX 

causes, more than half of the patients die. When operated upon, more 
than two-thirds recover. In the syphilitic cases the administration of 
the iodides and mercury sometimes effects a cure. When due to medi- 
astinal tumors, aneurysm, and enlarged glands, it may be necessary to 
remove a portion of the vocal cords pending the consideration of the 
operation or other treatment of the mediastinal disease. 

Treatment. — The faradic and galvanic currents have been used, and 
in but few cases with success. Antisyphilitic treatment has proved of 
value in a number of cases. Surgical treatment should be early recom- 
mended, as procrastination may lead to a fatal issue. 

Surgical Treatment. — Three methods of procedure are available, 
namely: (a) Tracheotomy, (b) intubation, and (c) laryngofissure and the 
removal of a part or all of the vocal bands. 

Tracheotomy is usually preferable, as it affords the least inconvenience 
to the patient and is ordinarily easily performed. The cyanosis, conges- 
tion, and edema of the tissues which sometimes complicate the case 
(A. G. Root) may, however, render this procedure difficult to perform. 
(See Tracheotomy.) 

Intubation may be performed for the temporary relief of the dyspnea. 
It is not suitable for permanent relief, as the tube may be coughed up, 
and its use is uncomfortable to the patient. 

Laryngofissure and the removal of a portion or all of the vocal cords 
may be practised if the tracheotomy tube is objected to. After this 
operation the vocal functions are sometimes gradually resumed. (See 
Laryngofissure.) 



CHAPTEK XXVIII 

THE SINGING VOICE 

The range of the average voice is from two to two and one-half 
octaves, although many singers embrace three to four octaves. 

The singing voice begins from the third to the sixth year, and changes 
but little until puberty. At this time there is a great change, especially 
in boys, in whom it becomes deeper or lower in pitch, assuming more 
the quality of the voice of an adult male. There is some change in girls' 
voices, although it is not so noticeable as in boys. The larynx becomes 
larger, the cartilages consolidated, and the cords longer and thicker. 

The vocal organs should not have special stress put upon them during 
this transition period, as coordination is distributed by the rapid changes 
in the shape, the size, and the position of the parts of the larynx. 

Voice production is dependent upon three functions of the vocal 
apparatus. By "vocal apparatus'' is meant the larynx (primary source 
of tone), the chest (source of motive power), and the resonant chambers 
of the chest and the head. 

Without the motive power of the outgoing current of air through the 
larynx there could be no vibration of the cords, and without the vibration 
of the vocal cords and the outgoing current of air through the upper 
respiratory tract there could be no vibration or secondary tones or 
harmonics to enrich the laryngeal or primary tone. In other words, a 
voice, to be pleasing or "sympathetic," must have all the qualities which 
can be imparted to it by a proper respiratory act, a normal placement of 
the larynx, and unimpeded vibration of the vocal cords; also the richness 
or quality imparted to it by the resonance chambers of the chest and 
the head. 

Defects of the singing voice are, therefore, largely due to the following 
causes: 

(a) Improper methods of breathing. 

(b) Improper action of the extrinsic and the intrinsic muscles of the 
larynx. 

(c) Local disease of the larynx. 

(d) Faulty or imperfect use of the resonance chambers of the head 
and the chest. 

The nose is one of the most important resonant chambers, hence 
diseases or abnormalities in this region are especially productive of 
harm to the singing voice. The epipharynx, the soft palate, the uvula, 
and the tongue are also largely concerned in voice production. Growths 
or diseased conditions of the epipharynx, the soft palate, and the tongue 
are therefore potent factors in defects of the singing voice. Enlarged 

(525) 



526 DISEASES OF THE LARYNX 

tonsils, especially if cicatrices interfere with the movements of the pillars 
of the fauces, mar the purity of the tone and interfere with its placement. 
The same is true of postnasal adenoids. In both instances the mobility 
and the normal action of the uvula form a curtain or valve which regulate 
the volume and the direction of the vibrating air current from the larynx 
in its passage through the epipharynx and the nasal chambers. It is 
important that their action should be free and untrammelled. Postnasal 
adenoids push the soft palate forward and downward, while enlarged 
and adherent tonsils interfere with its free movement in an upward and 
backward direction toward the posterior wall of the pharynx. A voice 
thus modified loses its charm. Not only is the quality or timbre impaired, 
but the range is also curtailed. I could cite instances in which the quality 
has been improved and the range increased one to three intervals by the 
removal of the tonsils. As adenoids are more obstructive in children, 
they do not greatly affect the adult voice. On account of an associated 
postnasal catarrh with adenoids, the singing voice is often thereby in- 
directly affected. Postnasal catarrh involves the postsuperior surface 
of the soft palate and produces a laxity of the tissues composing it, 
including the palatine muscles. There is an increase in the fibrous 
tissue, together with an edema (slight) and boggy condition of the 
muscle fibers. The uvula is relaxed and often hangs down until it touches 
the base of the tongue or the posterior wall of the pharynx. This gives 
rise to a tickling sensation, and is often a source of annoyance to singers 
and speakers. 

The presence of enlarged and diseased tonsils not only interferes with 
the muscular activity of the soft palate, but causes a chronic enlargement 
of the mucous membrane of the epipharynx and the mesopharynx, thus 
augmenting the catarrhal condition already mentioned. A very common 
symptom of tonsillar disease is a sensation of a splinter of wood lodged 
in the throat. This is a symptom which, so far as I know, has not here- 
tofore been attributed to this condition. I have often noted it, and 
regard it as significant of cryptic infection. 

Defects of the singing voice due to nasal diseases are chiefly due to 
an interference" with the production of the harmonics or overtones which 
give quality and character to the voice. The bones of the face are so 
constructed that there are numerous cavities communicating with the 
nasal chambers. The lightness of the bones makes them admirable 
sounding boards for the primary tones of the vocal cords. It becomes 
apparent at once that any condition of the nose which interferes with 
the proper entrance of the column of air into the nasal and the accessory 
cavities will prevent the voice taking on the rich qualities of tone which 
make it pleasing to the human ear. 

Deflection of the septum, thickening of the nasal mucosa from chronic 
catarrhal inflammation, polypi, and other morbid processes interfere 
with the resonant chambers of the head. The mucosa of the nose is 
reflected through the normal openings into the accessory sinuses, and is 
here affected by catarrhal or other thickening simultaneously with the 
invasion of the nasal membrane. The openings into the sinuses are more 



THE SINGING VOICE 527 

or less closed by the thickening, and the resonant quality of the cavities 
is thereby diminished. More often the middle turbinal or a high devia- 
tion of the septum blocks the nose and affects the resonance of the voice. 

Jean de Reszke has well said that the more he studies the voice the 
more he is convinced it is a question of the nose. I have for many years 
been impressed that the chief charm in a public speaker's voice is im- 
parted to it by the nasal resonance. If this were lacking it failed to hold 
the attention of his auditors. I only speak of this to emphasize the fact 
that there is something very attractive to the average person in the reso- 
nance of nasal origin. There seems to be no other quality that can take 
its place. What is true in this regard of the speaking voice is doubly 
true of the singing voice. 

The mouth influences the singing voice to a marked degree, not only 
in modifying the resonance, but, more particularly, in enunciation and 
articulation. The placement of the tongue, its concave-convex shape, 
with the tip elevated against the roof of the mouth, etc., modify the mu- 
sical quality of the voice. Hence, all abnormal conditions of the tongue 
which interfere with its movements affect the voice. If it is "tongue-tied," 
adherent to the anterior faucial pillars, or the geniohyoglossus muscle is 
too short, the musical value of the voice is impaired. Hypertrophy of 
the tongue is occasionally an impediment to the acquirement of vocal 
excellence. 

The larynx being the primary source of tone, it is natural to presume 
that most defects of the singing voice are due to some lesion or faulty 
method of using it. This is probably true, although it should be re- 
membered that many of the laryngeal inflammations are indirectly the 
result of nasal disease. Chronic laryngitis and, in many instances, acute 
laryngitis are secondary effects of chronic nasal obstruction and catar- 
rhal sinuitis. Recurrent or persistent hoarseness should, therefore, lead 
to a thorough inspection of the nasal chambers for obstruction or diseases 
of the sinuses. Hoarseness is not necessarily a sign of an antecedent 
nasal disease, as it is also a prominent symptom of laryngeal tubercu- 
losis, cancer, etc. 

Papillomata or other laryngeal neoplasms interfere with the motility 
and the adjustment of the vocal cords, and thus produce hoarseness, 
aphonia, or spasm of the muscles of the larynx. Morbid growths in this 
region should be removed with great care and with due regard to the 
functional integrity of the vocal apparatus. Awkward or aggressive 
surgery might forever banish the possibility of a musical career, or 
even a voice for ordinary social purposes. 

Any of the various forms of laryngeal paralysis described in the previous 
chapter will, of course, impair or entirely destroy the singing voice. 

Methods of Breathing. — Defects of the Singing Voice Due to Improper 
Methods of Breathing. — To obtain the purest and richest singing voice, 
the method of breathing should be carefully cultivated. The natural 
method of breathing is not suitable for the singing voice (H. Curtis). 
It is adapted to the ordinary function of oxygenating the blood, but is 
poorly suited for singing. For this purpose the respiratory acts should 



528 DISEASES OF THE LARYNX 

be done in such a way as to give the most perfect control over the expira- 
tory current, and at the same time maintain the same quality or tone 
of the voice during the varying stages of the act. 

In order to obtain the most perfect control of the expiratory current of 
air for artistic purposes, the respiratory method should be such as will 
give the greatest chest capacity, as well as full control over the emission 
of the air for phonatory purposes. 

The quality or timbre is best maintained throughout all the registers 
by such a method as will keep the upper portion of the thorax in a fixed 
position. 

The control of the expiratory current for artistic purposes is a complex 
coordination of the muscles of the chest walls (scaleni and intercostals), 
the diaphragm, the abdominal walls, and the larynx. The singer should 
not, however, be made conscious of the part the larynx plays in this 
capacity, as this would lead to an undue tension of the laryngeal muscles. 
Nothing could be more damaging to the quality of the voice than this. 
In fact, the larynx has but an infinitesimal muscular function in voice 
production. The singer should be made to understand clearly that 
only when the laryngeal muscles are at "ease" can the voice charm 
the listener. The auditory nerve should only be conscious of quality, 
richness, sweetness, fulness, splendor, unlimited reserve, and all the 
emotions that make the inner self a free spirit, travelling through the 
world of ennobled thought and imagination. The most beautiful song, 
when coming from an overtense larynx, calls attention to the material, 
the singer, as opposed to the ethereal, the song, thus defeating the 
purposes of artistic singing. 

I have thus digressed at this point in order to emphasize the impor- 
tance, indeed, the absolute necessity, of maintaining a proper poise of the 
laryngeal muscles during the artistic activity of the expiratory current 
of air with which the singing voice is produced. 

The Inferior Costal Type. — The chest cavity is conical in shape, with 
the apex at the top. It may be increased in all its diameters during the 
inspiratory act by the action of the scaleni, the intercostals, and the 
diaphragmatic muscles. All these muscles should, therefore, be used to 
fill the lungs to their greatest capacity. The inferior intercostals and 
the diaphragm are especially important for this purpose, hence it is 
usually spoken of as the inferior costal type. The upward and out- 
ward movement is chiefly confined to the ribs and the sternum below 
the sixth rib. The downward movement of the diaphragm pushes the 
abdominal viscera with it, and thus tends to increase the abdominal 
convexity. The experience of the great artists has shown that the lower 
portion of the abdominal walls should not be allowed to participate in 
this distention, as the perfect control of the expiratory current is thereby 
hindered. The lower portion of the abdominal wall should, therefore, 
be retracted, while the upper portion is allowed to distend. 

The upper chest wall should be maintained in the position it assumes 
during deep inspiration. That is, during expiration it should remain 
fixed in the position assumed during deep inspiration. In this way the 



THE SINGING VOICE 529 

resonance imparted to the voice by the thoracic cavity is increased and 
maintained of the same quality throughout all the registers of the voice. 
Failure thus to fix the upper chest wall will result in the voice taking 
varying tonal qualities as it passes from one register to another. I have 
heard singers whose voices were rich in quality in the middle register, 
but in passing into the upper or the lower register, assumed an entirely 
different quality. This change is not always due to a failure to fix the 
upper chest wall as described, as it may also arise from improper place- 
ment of the soft palate. Nevertheless, it is important that the upper 
wall of the thorax should be maintained in the position assumed during 
deep inspiration. 

The inferior costal or artistic type of breathing may be analyzed as 
follows : 

(a) It is chiefly performed by the inferior portion of the chest walls and 
the diaphragm. 

(b) The upper abdominal walls also participate in the outward expan- 
sion. 

(c) The inferior abdominal walls are maintained in a retracted position 
during inspiration and expiration. 

(d) The upper chest walls are maintained throughout inspiration 
and expiration in the position assumed during deep inspiration. 

The effects sought for are: 

(e) The greatest chest capacity. 

(/) Perfect control of the expiratory air current. 

(g) A maintenance of the same resonant quality throughout all the 
registers. 

Factors Which Influence the Voice. — Deviation from the foregoing 
type of breathing during the act of singing are detrimental to the artistic 
qualities of the voice. It is true that some of the greatest artists do not 
use this method of respiration. What their voices would have been 
had they used this method can only be conjectured. There are so many 
elements entering into the composition of a great artist, that a fault in 
one direction may be obscured or compensated for in other ways. For 
instance, an artist may use superior costal breathing and overcome 
in a large measure any defect of the voice resulting therefrom by the 
brilliancy of vocal execution or by the transcendent spiritual or mental 
conception which dominates the mind and the body during the singing. 
There is no shadow of doubt as to the transforming power of an exalted 
or overmastering conception of the part being rendered. This alone does 
not make one a great artist. The physical mechanism whereby this con- 
ception is expressed, should be so coordinated and adjusted as to not 
detract from its full expression. 

The Vocal Resonators. — The voice, like musical instruments, has its 
sounding board. The sounding board of the piano and the violin are 
familiar to all. If the string of a violin were stretched upon a heavy slab 
of marble the tone given off would be weak and disagreeable. It would 
lack the overtones or harmonics which make it rich and grateful to the 
ear. The same string when adjusted on a violin gives forth a tone of 
34 



530 DISEASES OF THE LARYNX 

great sweetness and power, as the sounding board adds numerous over- 
tones to the fundamental tone of the string. The fundamental tone 
predominates while the harmonies coordinate in such a way as to give it 
"color" or timbre. 

What is true of the violin string is also true of the vocal cords. The 
fundamental tone is weak and thin, but it is enriched by the harmonics 
of the resonance chambers of the chest and the head. 

The resonance chambers (sounding board) of the head are: (a) The 
ventricular pouches; (b) the pharynx; (c) the epipharynx; (d) the nares; 
(e) the accessory nasal cavities; and (/) the mouth. 

The resonance from the chest has been referred to under Methods of 
Respiration. 

The ventricular pouches do not, perhaps, play an important role in 
the production of overtones. The pharynx (including the epipharynx) 
communicates with the mouth and the posterior nares. The soft palate 
acts as a valve or curtain which regulates the amount of the vibrating 
current of air going to the nose and mouth. In this way the quality 
of the resonance is regulated to suit the musical expression of the singer. 
The soft palate is, therefore, an important part of the vocal apparatus. 
If it is elevated against the posterior wall of the pharynx, the voice 
assumes a peculiar and objectionable quality known as throatiness, a 
condition also assisted by the elevation of the posterior portion of the 
tongue (H. Curtis). 

The soft palate is prolonged downward in two pairs of folds known 
as the pillars (palatine arches) of the fauces. 

The anterior pillar contains the palatoglossus (glossopalatine) muscle, 
while the posterior pillar embraces the palatopharyngeus (pharyngo- 
palatine). They assist in the modulation of the voice by coordinating 
with the movements of the soft palate. The function of the uvula is 
not well understood. 

The faucial tonsils lie between the pillars, and when enlarged or dis- 
eased, affect their motility and impair the voice. They often become 
adherent to the sinus tonsillaris and thus very materially interfere with 
their action. I have no hesitancy in indorsing the opinion of Sir Morrell 
Mackenzie, H. Curtis and others who advocate their removal in adults 
when they give rise to the slightest trouble. Curtis says their existence 
in the adult is unnecessary, as they serve no good purpose. When we 
remember that in childhood they are composed of lymphatic tissue, 
to meet the exigencies of the infectious fevers to which childhood is so 
susceptible, and that in adulthood they are usually fibrous from repeated 
and long-continued inflammation or irritation, it is easy to understand 
why they no longer serve any useful purpose. 

If the pillars are adherent to the tonsils, they should be freed, and in 
most instances this should be followed by complete ablation of the 
tonsils. (See Operations of the Tonsils.) The immediate effect of their 
removal is sometimes detrimental to the voice. After a few weeks this 
passes away and the voice begins to show the value of the procedure. 
At first the loosened pillars may relax and fail to perform their muscular 



THE SINGING VOICE 53I 

function. After a few weeks they become attached to the fibrous tissue 
formed in the sinus tonsillaris, and perform their functions in a much 
better manner than before the tonsillectomy. Sir Morrell Mackenzie 
says he has never seen any other than beneficial effects to the voice 
follow their removal. 

The pharynx is supplied with numerous lymphatic masses, especially 
near its vault and along the lateral walls. The enlargement of the 
lymphatic tissue in the vault is commonly known as postnasal adenoids, 
while that along the lateral walls of the pharynx is called pharyngeus 
hypertrophica lateralis. When the scattered masses over the posterior 
wall of the pharynx are diseased and enlarged, the condition is known 
under various names as follicular pharyngitis, granular pharyngitis, or 
"clergymen's sore throat." 

Adenoids are not commonly present in adults, although they may be. 
Many children, however, have marked defects of the voice from their 
presence. The resonance is interfered with by the obstruction in the 
epipharyngeal space and the entrance to the nares. The soft palate is 
crowded forward and downward by them. The voice has a dead or so- 
called "nasal" quality, which in reality is an absence of nasal resonance. 
In other words, the nasal chambers are the chief resonators of the voice. 
It is obvious, then, that adenoids are an absolute hindrance to the singing 
voice. The treatment is their complete removal (see Adenoids). 

Hypertrophica lateralis impairs the voice by perpetuating a chronic 
irritation and congestion of the parts, including the larynx. The voice 
becomes husky and the muscles of the larynx tire upon slight or moderate 
singing. The hypertrophic glandular masses should be removed. 

"Clergymen's sore throaty or chronic pharyngitis, is, according to Sir 
Morrell Mackenzie, the most common cause of trouble to singers, the 
voice becoming husky and tiring upon slight use. Just behind the soft 
palate the muscles of the posterior pharyngeal wall contract in coordina- 
tion with those of the soft palate, and aid in closing or constricting the 
pharynx at this point. Resonance is, therefore, modified by the existence 
of inflammatory disease of the pharynx, as the muscles of the pharynx 
and the soft palate are edematous and somewhat restricted in their 
movements. 

Chronic pharyngitis is accompanied by a similar affection of the 
posterior wall of the soft palate and the uvula. A relaxed or elongated 
uvula is nearly always a sign of chronic epipharyngitis. The practice 
of amputating the uvula under such circumstances should not be done 
without first attempting to cure the preexisting pharyngitis. 

The tongue performs an important function in regulating the reso- 
nance chamber of the mouth. If there is a shortening of the geniohyo- 
glossus muscle, or an hypertrophy of the entire tongue, this function 
is impaired. I have frequently seen the tongue adherent quite high 
on the anterior pillars of the fauces. This not only interferes with the 
correct movements of the tongue, but with those of the anterior pillars 
also. In one case of this kind, where the tonsils had been completely 
removed by cautery dissection, hoarseness became a troublesome factor. 



532 



DISEASES OF THE LARYNX 



Lingual tonsils and varicosities sometimes give rise to hoarseness and 
a web-like feeling in the larynx. 

"Tongue-tie" interferes with the proper performance of the glossal 
function, especially in articulation. 

The absence of some of the front teeth, or even marked irregularity of 
the same, might also interfere with resonance and articulation in singing. 

Cleft palate (either hard or soft) would, for obvious reasons, interfere 
with both resonance and articulation. 

The Nasal Chambers. — As these are the chief resonators or sounding 
boards of the voice, special attention should be directed to their condi- 
tion in searching for defects of the singing voice. This is of special 
importance in view of the fact that many pharyngeal and laryngeal 
affections are caused by preexisting disorders of the nose. 

The nose is divided into two cavities by the nasal septum, and these 
cavities are still further partially divided by the turbinated bodies. 
The lateral walls of the nares are in communication with numerous 
air cells or sinuses which communicate with the nasal chambers. Above 
the nose they open into the frontal sinuses, while posteriorly they open 
into the sphenoidal sinuses. Thus the bones of the face form numerous 
bony chambers which make up the chief sounding board of the vocal 
apparatus. At least it is this portion of the resonance apparatus that 
gives the voice its sympathetic and attractive quality. I would not mini- 
mize the importance of the chest and other resonance chambers, but I 
would emphasize the importance of the resonance chambers of the nose. 

Defects of the Singing Voice from Improper Methods of Respiration. — 
While there can be no well-defined analysis of the defects due to improper 
methods of breathing, there can, nevertheless, be a classification which 
will emphasize the underlying principles. The following is given for 
this purpose rather than to catalogue a series of defects: 

(a) Superior costal breathing does not use the entire thoracic capacity, 
hence the voice does not possess the reserve force and the evenly sus- 
tained quality afforded by the inferior costal type of breathing. 

(b) The same may be said of the abdominal type of breathing with 
even greater emphasis. The resonance is less pronounced than in either 
the superior or the inferior costal type, while the control of the expiratory 
breath is jerky. The voice is thereby rendered uneven and less sym- 
pathetic in quality. 

(c) On account of the greater difficulty in controlling the expiratory 
breath, the extrinsic and the intrinsic muscles of the larynx are put upon 
a tension in an involuntary attempt to compensate for the lessened control 
of the thoracic and the abdominal muscles. This at once impairs the 
artistic qualities of the voice and in some cases almost destroys its sing- 
ing qualities. The voice becomes rough, metallic, unsympathetic, and 
forced. The laryngeal muscles tire easily, and prolonged singing is an 
impossibility. There is a feeling as of a web across the cords. Frequent 
ineffectual attempts are made to clear the throat. 

The foregoing symptoms may be present in so slight a degree as to 
escape notice, or they may be so severe as to ruin the voice. 



THE SINGING VOICE 533 

The inferior costal or artistic type of breathing, if intelligently and 
faithfully practised, will avoid these difficulties and add materially to the 
power and attractive qualities of the singing voice. 

Defects of the Singing Voice Due to Tone Blindness. — J. Mount-Bleyer 
has called attention to a condition of the hearing centres of the brain 
which is neither a disease nor a defect, but is the result of inattention 
or lack of training. For instance, some hear an orchestra as a whole, 
while others distinguish the tone of each instrument; still others dis- 
tinguish the exact musical quality of each instrument. The difference 
is not so much in the mechanism of hearing as it is in the training which 
the brain centres have received. One, through a love of music, seeks 
for the finer qualities and variations, while another casually receives 
only the most general impressions from music. In the first place, there 
is eager, expectant attention, while in the latter there is an indifferent, 
passive attention. It cannot be said that one has a good ear and the 
other a poor ear. Each may have equally good ears, or the one hearing 
the less may have the better. One, however, has a cultivated brain 
centre, which enables him to distinguish tones and qualities unnoticed 
by the other. Suitable training of mechanically perfect "ears which 
hear not," and "ears that hear and hear not," would rapidly convert 
them into highly discriminating organs of hearing. 

We often hear the remark, "I do not sing because I have no ear for 
music." In other words, he sings poorly because he has not educated 
the so-called ear to a full appreciation of musical intervals, rhythm, and 
the other qualities which make music so attractive. His belief is that 
his ears are defective as to musical matters, while the opposite may 
be true. The whole matter may be summed up in the statement that 
his "ears" have not been educated. 

J. Mount-Bleyer refers to Mr. Evans' work as superintendent of 
singing in the London schools, where he has 300,000 pupils under his 
direction. In no instance of obstinate inability to distinguish one sound 
from another has he failed to educate them to appreciate such distinc- 
tions. This fact is significant, and should encourage those interested in 
the cultivation of the voice to give more attention to the exact education 
of the "ear." 

Treatment. — I will here briefly outline the method of procedure used 
by M. Duchemin, director of music in the asylums of Paris: 

"M. Duchemin, setting aside all ideas of notations, commences by 
demonstrating to the pupil, by means of any musical instrument whatever, 
the interval of a note and that of a half-note. When the pupil has been 
sufficiently instructed in the distinction of these intervals, he makes him 
listen to the interval of a note and to that of a major third. He next 
makes him compare the major third with the fourth, and thus successively 
all the major intervals of the same octave. He then returns to the point 
from which he started, and makes him compare the major with the minor 
intervals. When the pupil is acquainted with all the ascending intervals, 
he then repeats all the intervals, but in the descending scales. Finally, 
when the pupil has compared all the intervals by twos and twos, 



534 DISEASES OF THE LARYNX 

M. Duchemin makes him listen to isolated intervals, either ascending or 
descending, at first to those comprised within a single octave, afterward 
to those within two octaves, and so on." (J. Mount-Bleyer.) 

I have recently tried this method in a few cases where the claim was 
made that they "had no ear for music," with gratifying results. The 
quickness with which they learned to differentiate between the various 
intervals was surprising to me. Both vocal and instrumental music, 
including the orchestra, assumed a new and delightful place in their 
lives. I would, therefore, urge that further attention be given to this 
part of the subject. 

It is not within the province of this work to speak of methods of teach- 
ing, except in so far as they may apply to the defects of the singing voice. 
I cannot refrain, however, from the remark that, in my judgment, M. 
Duchemin's method of procedure might be used with greater advantage 
in both vocal and instrumental instruction as a preliminary training in 
musical education. Public schools, conservatories of music, and private 
teachers might, with great advantage to their students, follow this method. 
As music is made up of these intervals arranged in varying rhythm, 
periods, and sequence, it is of primary importance that the ear be trained 
to recognize them readily. This is all the more apparent when we re- 
member that only when sensory impressions become intimate parts of 
one's experience can they be reexpressed with power and beauty. An 
"ear" trained in this way will not only hear the music of others more 
accurately, but its possessor will be able to render music more accurately 
himself. 

I wish here to consider a few of the more common conditions which 
impair the singing voice. 

Laryngitis of a subacute or chronic type is one of the most frequent 
derangements of the vocal apparatus to be found among singers. It 
renders the voice slightly rough or hoarse, and in extreme cases aphonic. 
The impairment is not constant, but comes and goes with the changes of 
the weather or with fatigue and use of the voice. Its tendency is to 
become more and more fixed with each recurrence. The etiology may 
be embraced in an antecedent nasal disease, an improper use of the 
laryngeal apparatus, or in some general condition which lowers the vital 
energy. If it is due to the first, the nose and the epipharynx should 
receive appropriate attention, with a view to restoring their respiratory 
functions. Nasal obstruction, chronic sinuitis, etc., should be treated 
according to the descriptions given elsewhere in this work. The hoarse- 
ness may be due to an improper use of the vocal apparatus; the faulty 
method should be detected and corrected if possible. Six years ago a 
lady consulted me concerning her throat, stating that she was a student 
of vocal music, and that after moderate use of the voice she became 
slightly husky, there being a sensation of a web over the cords. Upon 
examination of the nose and throat, I could detect no apparent cause for 
the condition. I found her, however, to be quite "high-strung," and 
asked her to go through some of her exercises in my presence. It was 
quite apparent that the whole muscular system, including the larynx, 



THE SINGING VOICE 535 

was of a " high tension." As she was a woman of culture and intelligence, 
I explained to her the necessity of overcoming this overtension, and 
offered her some suggestions as to how to do it. She was told to assume 
a natural and comfortable position in the chair, and to allow her arms, 
including the hands, to drop at her sides in extreme relaxation. She 
was then to allow the whole body, including the tongue and the lower 
jaw, to participate in the relaxation. Next she was to hum very softly 
the note that came naturally to her throat. After she had gone through 
with this exercise for a few minutes, the vocal exercise was varied by 
singing the tones within a range of one-half octave, cautioning her all 
the time to maintain extreme relaxation of the whole body. The exer- 
cises were gradually broadened to those she was in the habit of singing, 
the difference being in her physical condition during their production. In 
a surprisingly short time she thus trained the extrinsic and the intrinsic 
muscles of the larynx to a normal tension, which not only caused the 
hoarseness to disappear, but resulted in a placement of the larynx which 
gave added richness to her voice. There were poise and dignity in it, 
which were hitherto undeveloped. 

I do not mean to imply that all persons suffering from "high tension" 
can be made to sing beautifully, but I do want to say that many singers 
who become hoarse from overtension of the laryngeal muscles may be 
speedily and effectually relieved of the hoarseness and other tension 
anomalies of the voice by suitable advice and vocal exercises. The 
manner of going through with the exercises should be emphasized. 

If the hoarseness is due to some general systemic disturbance which 
results in laxity of the cords or the laryngea mucosa, remedies suited to 
the case should be given. 



CHAPTER XXIX 

DEFECTS OF SPEECH 

Defects of speech are due to a great variety of causes, most of which 
are extr alary ngeal. The larynx is the primary source of spoken tones, 
but it is not the complete vocal apparatus. It has been customary, in 
times past, to speak of it as the vocal organ, but this can no longer be 
done in strict conformity to well-known facts concerning voice produc- 
tion. While the vibrations of the vocal cords produce the primary tone, 
it is much modified by the chest, pharynx, epipharynx, nasal and acces- 
sory chambers, tongue, and the mouth. The character of the tone is 
also somewhat dependent upon the respiratory movements of the chest, 
abdominal muscles, and diaphragm. The voice changes when there is 
a marked increase in the physiological activity of other parts of the body, 
as at puberty. This is especially noticeable in boys. Mental states 
exert a marked influence on the quality of the voice, as may be noted in 
anger, joy, hatred, and love. 

It is, therefore, apparent that defects of speech may have their origin 
in parts remote from the laryngeal apparatus. The demands of domestic 
and social life often make it important that one possess a voice that is 
pleasing in timbre, range, pitch, and modulation, as well as in articulation. 
Hence, attention should be directed to some of the more important lesions 
which impair the quality and integrity of speech. 

Speech and Brain Development.— That there is an intimate connec- 
tion between the development of the organs of speech and the cerebral 
centres of intelligence is, I think, scarcely open to question. This is 
especially true in children. I have seen them four years of age, apparently 
as bright and intelligent, with the exception of speech, as other children 
of the same age. They had reached the age at which spoken language 
should be used to communicate their wants and express their ideas. If 
it is not acquired within a reasonable length of time, they are in danger 
of becoming mentally inferior to other children of the same age. That 
this inferiority is not altogether due to their inability to acquire knowledge 
through the senses, and through the natural inquisitiveness of childhood, 
has been shown by various writers who have reported remarkable in- 
crease in the mental development in children who were only trained 
to use the muscles of articulation, not yet having been led into the realm 
of thought in which information concerning things and affairs is incul- 
cated. Makuen, of Philadelphia, reports cases in which the simple 
training of the muscles of the mouth, tongue, and fauces aroused the 
dormant faculties of the brain. The use of the motor tracts, of the 
muscles of speech, stimulated the centres of speech and thought, and 
(536) 



DEFECTS OF SPEECH 537 

the patient passed rapidly from a "backward child" to one of ordinary 
intelligence. 

I will not at this time consider fully the interdependence of the organs 
of speech and mental development, but will only thus briefly refer to it 
in order to emphasize the importance of slight impediments of speech 
in children who are of the age at which language is most naturally 
acquired. It is obvious that an impediment at this time is a much more 
serious hindrance than it is after speech has been acquired. It is very 
much easier for him to cover up or compensate for a defect in the organs 
of speech, if the faculty of speech has been already acquired, than it is 
if that faculty is not developed. Hence, abnormalities of the organs of 
speech, which develop after speech has been acquired, result in but 
slight defects of speech; whereas abnormalities of a similar nature, in a 
child who has not yet acquired the faculty of speech, will in some cases 
prevent the acquisition of spoken language, while in others it will only 
interfere with it to such an extent as to make it defective. If this were the 
extent of the damage done, it might be passed over with comparative in- 
difference; but, as I have already suggested, mental development is also 
hindered. I have no doubt that a considerable number of the so-called 
" backward children" coming under this category are so chiefly on 
account of a slight physical imperfection of some part of the organs of 
speech. I do not mean to say that all " backward children" come under 
this classification, as no doubt many of them are defective in cerebral 
development from quite different causes. I only wish to call attention 
to the fact that each case should be carefully studied, the physical im- 
pediments to spoken language corrected, and suitable training of the 
organs of speech instituted, in order to give the child the best possible 
chance of taking the position in society to which he was born. 

An analysis of the peripheral causes of the defects of speech is inter- 
esting as well as instructive, especially to those who meet them in practice, 
or at least to those who attempt to treat them. Defects of speech are 
subdivided into six varieties by R. Cohen, of Vienna, as follows: 

1. Stammering. 

2. Stuttering. 

3. Nasal twang. 

4. Defects due to malformations of the hard and soft palates. 

5. Deaf-mutism. 

6. Defects of speech due to diseases of the central nervous system. 
Instead of following the classification given by Cohen, the author will 

treat the subject under the following heads: 

1. Defects of speech of nasal origin. 

2. Defects of speech of epipharyngeal and faucial origin. 

3. Defects of speech of lingual origin. 

4. Defects of speech of laryngeal origin. 

5. Defects of speech of thoracic and abdominal origin. 

6. Defects of speech due to deaf-mutism. 

7. Defects of speech due to malformations of the palate. 

8. Defects of speech of central origin. 



538 



DISEASES OF THE LARYNX 



1. Defects of Speech of Nasal Origin. — The etiology may be: (a) 
Deflection of the septum, (b) Spurs or ridges on the septum, (c) Split 
or double convexity of the septum from an old traumatic lesion or abscess. 
(d) Nasal polypi or other neoplasms, (e) Chronic turgescence of the 
inferior nasal concha?. (/) Hypertrophy of the inferior nasal conchse. 
(a) Hypertrophy (mulberry) of the posterior ends of the inferior and 
middle conchse. (h) Congenital occlusion of the posterior nares. (z) 
Displacement of the columnar cartilage, (y) Enlargement of the middle 
conchas from hyperplasia or cystic degeneration, (k) Obstruction to 
the olfactory fissure. 

The foregoing conditions do not cause great defects of speech, as 
they only interfere with the resonant quality of the voice. Nor do 
they materially interfere with the muscular mechanism of speech pro- 
duction. 

In a general way, they may be said to produce those changes in the 
voice which make it "dead/' "muffled," "thick," "flat," or lacking in 
resonance. The speech is still further modified by diffidence, which so 
often accompanies nasal obstruction. The diffidence, backwardness, or 
timidity is due to a self-consciousness, to which the defect gives rise, 
and to a direct effect upon the brain and general system, through the 
lymphatic and venous stasis attending nasal and postnasal obstruction. 
Guye, of Amsterdam, has called attention to a condition which he calls 
"aprosexia," or difficult attention. 

Inability to fix the attention is often attended with diffidence and 
timidity, and not only is articulation impaired thereby, but fluency 
and coherency is also somewhat affected. 

The elementary sounds of spoken language which depend largely 
on the resonance of the nasal chambers are not so markedly impaired 
as those but slightly depending upon it. For instance, the letters m, n, b, 
and d derive their peculiarity from the initial sound, while the final vowel 
and nasal tones are secondary. Notwithstanding the fact that they are 
secondary, their absence or suppression makes a noticeable change in the 
speech, and amounts to a defect. If the final vowel-nasal sound in the 
above examples were more prominent, the nasal obstruction would not 
interfere with speech nearly so much, as the speaker could " force" them, 
and thereby somewhat overcome the apparent effects of the stenosis. 
The letters m and n end in a kind of "hum" which is very difficult to 
produce when nasal obstruction is present, especially when the hum is 
somewhat suppressed. 

The letters b and d seem to begin with the sound thrown forward 
against the lips (b) and against the tip of the tongue and roof of the 
mouth (d) respectively. The initial sound is, however, made in the 
larynx and rendered resonant in the chest and nasal chambers. Nasal 
obstruction modifies the resonance, thus causing a "dead" or "flat" 
tone to explode at the lips or the tip of the tongue. Thus the speech 
is rendered defective. We might continue the analysis of the various 
sounds in speech, showing how nasal obstruction, from one or more of 
the foregoing conditions, affects the beauty, music, rhythm, and coherency 



DEFECTS OF SPEECH 539 

of speech. We might go still farther and show that coherency of thought 
is impaired also. 

2. Defects of Speech of Epipharyngeal and Faucial Origin.— These 
may be caused by the following: (a) Postnasal adenoids. (6) Fibroma 
or other neoplasms of the nasopharynx (epipharynx). (c) Chronic 
catarrhal thickening of the mucosa of the epipharynx. (d) Hyper- 
trophied or hyperplastic faucial tonsils, (e) Adhesions of the anterior 
and posterior pillars of the fauces to the tonsils. (J) Depression o? the 
soft palate against the root of the tongue by the postnasal adenoids, (g) 
Paralysis of the palatine muscles, especially those of the membranous 
curtain which control the current of air passing to the nares. (h) Par- 
alysis of the soft palate and uvula, (i) Adhesion of the anterior faucial 
pillars to the base of the tongue, (7) Cleft soft palate and uvula, (k) 
A shortened soft palate, as is sometimes found after operation for cleft 
palate. 

In the above table the muscular mechanism of speech is affected, and 
the defects of speech are correspondingly more pronounced. The explana- 
tion of the more marked defects which seem to have their origin in this 
classification is not as easy as may appear on first thought. We cannot 
say that the speech is defective because the muscular action of the parts 
is interfered with, because many cases come under our observation in 
which there is great muscular impairment but little impediment of 
speech, while others can scarcely be said to have articulate speech at all; 
and in still others they cannot be said to have coherent thought. The 
explanation in some cases is that the muscular impairment existed 
quite early — before articulate speech was acquired. The impediment 
thus interfered with the acquirements of articulate speech. The presence 
of postnasal growths produced mental hebetude (aprosexia), heretofore 
referred to, and the mental ability to acquire articulate speech and 
consecutive thought was thus impaired. In a few years the growing 
child becomes more vigorous in mind and body, and makes renewed 
and voluntary efforts at articulate speech. His failures humiliate and 
irritate him. He avoids the necessity of speech as much as possible. 
The speech centres and motor vocal tracts are little used and lie dormant. 
His mental growth is thereby retarded. The sensitive, reticent child 
loses the mental growth to be gained by spoken language. He becomes 
and is regarded as a "backward child." 

It becomes the duty and privilege of the rhinologist and laryngologist 
to loosen the bonds which fetter his imprisoned mind, thus enabling him 
to enjoy the common pleasures of life, even though he may never become 
a brilliant member of society. 

3. Defects of Speech of Lingual Origin.— The causes may be: 
(a) Inflammatory adhesions binding the tongue to the anterior faucial 
pillars and epiglottis, (b) A congenital shortness of the geniohyoglossus 
muscle, (c) Tongue-tie. (d) Enlargement of the tongue, (e) Excessive 
enlargement of the lingual tonsils. 

Of the foregoing, the most important are adhesions of the tongue to 
the anterior faucial pillars, tongue-tie, and shortening of the genio- 



540 DISEASES OF THE LARYNX 

hyoglossus muscle. Either condition materially interferes with the 
articulatory function of the tongue, thus impairing speech. _ Lisping 
is a common sign in these conditions. If these lesions exist prior to the 
acquirement of speech, they may give rise to the clinical picture hereto- 
fore referred *to under " backward children." The early correction of 
these physical imperfections may place the child on an equal footing 
with his fellows, and save society the disagreeable presence of a crippled 
mind in its midst. 

4. Defects of Speech of Laryngeal Origin.— The etiology may 
be: (a) Too great strength in the uplifting muscles of the larynx, (b) 
A weakness of the down-pulling muscles of the larynx, (c) Laryngitis. 
(d) Chorditis nodosum, (e) Tuberculous inflammation and infiltra- 
tion. (/) Perichondritis, (g) Laryngeal rheumatism, (h) Catarrhal 
accumulations, (i) Neoplasms. ( j) Paralysis of the intrinsic laryngeal, 
muscles. 

If the acute affections of the larynx, as laryngitis, and the chronic 
conditions, such as chronic laryngitis, laryngeal tuberculosis, perichon- 
dritis, paralysis, rheumatism, and neoplasms which cause hoarseness or 
aphonia, are omitted, there is little to catalogue as causes of defects of 
speech. This is the more surprising when we recall the fact that the 
larynx is the primary source of the voice. 

Makuen has referred to a condition of the extrinsic muscles of the 
larynx which rendered the voice sibilant and falsetto. It is given in the 
table above in a and b, and is interesting because it illustrates one of 
the fundamental problems in voice culture, namely, voice placement. 
If the larynx is allowed to rise too high, the voice becomes falsetto and 
unnatural in quality. If, on the other hand, the laryngeal box is held 
down in its proper position, the voice assumes its natural register, the 
tone being pure and pleasing to the ear — that is, it is natural. 

The natural and simple things of life appeal most strongly to normal 
minds. The simple rural scenery, the grandeur of the mountains, the 
simple melodies of the negroes, the rugged vitality of the Wagnerian 
opera, and the eloquence of the orator stir the imagination, quicken 
and fascinate the mind, as the unnatural, the complex, and the artificial 
cannot do. 

Hence, the aim should be to give those having defective speech a 
speech that is simple and natural. It should be natural in quality, 
tone, pitch, timbre, and rhythm, as well as in modulation and articu- 
lation. 

5. Defects of Speech of Thoracic and Abdominal Origin.— The 
causes may be: (a) Pulmonary tuberculosis in its relation to stammer- 
ing, (b) Irregularity of the respiratory rhythm. 

Irregularity of the respiratory movements is an almost constant factor 
in stammerers. Whether this is due to some fault of the respiratory 
centre, or to some peripheral lesion, has not yet been determined. 
Makuen has called attention to the fact that all, or nearly all, stammerers 
are either tuberculous, or come from families with this disease well 
marked in its history. He thinks the peripheral tuberculous lesion 



DEFECTS OF SPEECH 541 

accounts for the irregularity of the respiratory rhythm, which in turn 
causes the stammering. 

His conclusion is not necessarily correct, as the lack of rhythm may 
be due to developmental causes within the medulla, or along the motor 
nerve tracts leading to the diaphragm, lungs, and intercostal muscles. 
It is a well-recognized fact that those having a tuberculous tendency, 
especially those inheriting it, have a lowered cellular vitality, and that 
nutrition, or the processes of metabolism, are imperfectly performed. It 
is therefore possible to explain the lack of respiratory rhythm as being 
the result of the malnutrition and faulty development of the respiratory 
centre and the motor respiratory tracts. 

Whatever the explanation may be, the clinical fact remains, that 
nearly all persons who stammer are of tuberculous parentage and com- 
plain of ill health. Another fact, however, which makes it seem probable 
that the lesion is peripheral (in the lungs and diaphragm) is that under 
suitable treatment and training they may be freed from the defect. 

La Fayette Page calls attention to intoxications arising from diseased 
conditions of the upper respiratory tract. He cites the work of Schwalbe 
and Retzius, who demonstrated the connection of the lymphatic vessels 
of the nasal mucous membrane and those of the cranial cavity. Through 
the lymphatic and venous stasis of the nasal mucous membrane, the 
effects extend to the cranial cavity, thus giving rise to mental dulness. 

He also cites the intimate nervous connections between the nasal 
mucous membrane and the cortical centres of the brain as a possible 
source of mental dulness and irritability. 

Makuen in his writings seems to lay greatest stress on impairment of 
the organs of speech, as the larynx, fauces, nose, or tongue, as the chief 
hindrance of mental growth and development. 

In the opinion of the author, defects of speech and mental acumen 
are due to complex conditions which it would be difficult to define. It 
appears, nevertheless, that children who are defective in speech are 
improved by correcting, either surgically or by training, the physical 
impediments to speech. We also know, from clinical observation, that 
upon the removal of postnasal adenoids or section of the geniohyoglossus 
muscle, etc., the mechanism of speech and the mental activity of the 
child are often much improved. Those who hold, as Guye and Page, 
that the mental quickening is due to the removal of the cause of the 
venous and lymphatic stasis, overlook the fact that the mechanism of 
speech is at the same time improved. The soft palate which was crowded 
down against the base of the tongue is freed, or the tongue is loosened, 
and resumes its normal function in articulate speech. Again, those who 
hold the views of Makuen to the exclusion of all others overlook the fact 
that the venolymphatic stasis, with its attendant toxemia and brain 
hebetude and irritability, is overcome and allows the brain to resume 
its normal activity. 

It should not be forgotten that the toxemia referred to by Page affects 
the system much deeper than the brain. The whole system is poisoned, 
as has been shown by the author in various articles on mouth breathing. 



542 DISEASES OF THE LARYNX 

There may be great imperfection of speech without impairment of 
the mental faculties. Nevertheless, it must be said that in nearly all 
cases "the speech belieth the man." 

Elegance of speech is an index of a finished mind. Training the 
organs of speech improves not only the expression of thought, but the 
thought itself is more elevated, more finished. The quality of mind is 
improved by a better mode of expression. 

6. Defects of Speech Due to Deaf-mutism. — This subject is quite 
fully considered under deaf-mutism, and will only be briefly analyzed 
here. It may be caused by: 

(a) Congenital defect of the auditory apparatus. 

(b) Acquired defect of the auditory apparatus. 

(c) Nasal and epipharyngeal diseases. 

(d) Improper and untimely training. 

(e) Lack of training. 

Congenital defects of the auditory apparatus are probably present in 
about one-half of the cases of deaf-mutism, whereas in the balance the 
defect is due to the ravages of some disease, usually one of the exan- 
thematous fevers. In either instance the child is partially or totally deaf, 
and cannot, therefore, readily acquire the faculty of speech. He is not 
mute because the organs of speech are defective, nor because the centres 
of speech are impaired. Both the peripheral organs of speech and the 
central mechanism of the brain may be in perfect condition. The child 
is mute because he cannot hear others speak, and is thereby deprived 
of the most useful aid in learning — namely, imitation. If he learns to 
speak, he must be taught by other and more difficult methods. He 
must be given timely and proper special training. If he has acquired 
deaf-mutism after having some ability to speak, he may not be a mute 
in the full sense of the word, but may need some special training to 
prevent his losing the little speech he already possesses. If the deaf- 
ness comes before the seventh year of age, there is a strong tendency 
to lose the faculty of speech; hence, special training is necessary to 
maintain that already acquired, as well as to broaden it. If the deafness 
comes on after the seventh year, the patient rarely loses the faculty of 
speech ; hence, his training can be more simple than that of a child losing 
his hearing before that age. 

Reference has been made under Deaf-mutism to the interdependence 
of the brain development and the use of the organs of speech. Brain 
development and intellectual growth depend largely upon the voluntary 
use of the organs of speech. It is a common observation with most of us 
that an idea or train of thought is much clearer after having been ex- 
pressed in words. The growth of the brain seems to depend upon the 
cooperation of the various senses and the peripheral organs. The intelli- 
gence of the child will, therefore, largely depend upon the use of its vocal 
apparatus, as well as all the other peripheral organs of the body. 

At certain ages the various faculties of the brain develop most naturally, 
and these periods should be taken advantage of by his instructors. At 
one time the imagination, which later in life finds expression in so many 



DEFECTS OF SPEECH 543 

practical ways, has the ascendancy. The training at this period should 
be of such a character as to lead the imagination along wholesome lines. 
It should be bridled, but not suppressed. When adulthood is reached, 
and the practical affairs of life must be faced, the faculty once known 
as imagination is utilized in foreseeing the outcome of a given series of 
events. Cause and effect, and the sequence of events, will be correctly 
interpreted, somewhat in proportion to the character of the training 
received during the imaginative period in childhood. 

The other faculties of the mind should also receive due consideration 
in the training of the child. The child that is deaf needs this training 
tenfold more than the one with normal hearing. It becomes obvious, 
therefore, that the deaf mute needs a teacher well schooled in the knowl- 
edge of the child mind, that he may facilitate its unfolding in the most 
wholesome and natural manner. Not one mother in ten thousand is 
fitted for this task, and even if she were, her love for the child would 
probably make her its worst enemy, in so far as its proper training and 
restraint are concerned. The proper thing to do, therefore, is to place 
the child who is a deaf-mute under the care of the most competent 
teacher available for the purpose, at the earliest possible time, certainly 
before the sixth year of age. 

The child that has no training will remain a deaf-mute. He may 
go through the manual sign language, learn to communicate with his 
fellows, but he will always be much handicapped in the race of life, as 
his communication with his fellows must be limited to the few who have 
likewise learned the sign language. Then, too, he is forever debarred 
from the pleasure and developmental power derived from the mechanical 
action of the vocal apparatus, and the pleasurable sensation experienced 
in ventilating the blood and stimulating articulation, which accompany 
voice production (Makuen). 



CHAPTEE XXX 

NEOPLASMS OF THE LARYNX 

Benign tumors of the larynx and the trachea are characterized by 
the absence of pain and by non-recurrence. Malignant neoplasms, on 
the contrary, are characterized by pain, recurrence, and destructive 
processes. 

Varieties. — Almost all types of benign tumors which occur in other 
parts of the body are found also in the larynx. The following are more 
or less frequently reported in the literature: papilloma, fibroma, myxo- 
fibroma, polypus, cystoma, lipoma, telangiectases, chorditis nodosa, and 
pachydermia laryngis. 

Location. — In looking over the literature for a period of ten years, I 
found lipoma and cystoma on the epiglottis; cystoma on the ventricular 
pouches; lipoma, cystoma, and papilloma in the arytenoid region ; polypus 
telangiectasis, fibromyxoma, papilloma, fibroma, singer's nodules (chor- 
ditis nodosa), and myxocystoma on the upper surface of the vocal cords 
and in the subglottic region. These and doubtless other benign neo- 
plasms occur in the locations indicated. 

Etiology. — Much has been written, while but little is known, concern- 
ing the exciting causes of these growths in the larynx. 

Jonathan Wright says: "There is a strong likelihood that if these 
tumors are not the result of chronic inflammatory changes, the chronic 
inflammations play an important role in their etiology, and that this 
should be borne in mind in the treatment." They occur at all ages, but 
most frequently in middle adult life. Papilloma, however, occurs more 
frequently in children, and measles is apparently a prolific exciting cause. 
Both men and women are affected, but the tumors are found more fre- 
quently in men. Sir Felix Semon has called attention to the fact that 
they are thought to occur more frequently in Germany and France than 
in the United States or England. 

Benign neoplasms are relatively common among street vendors, singers, 
and speakers. Congenital tumors are rare. Papilloma is the most com- 
mon variety. The anterior commissure is the most frequent site for 
laryngeal tumors. Lipoma rarely occurs within the cavity of the larynx, 
but is located extrinsically on the anterior surface of the epiglottis. 
Syphilis and tuberculosis, though they produce growths of their own 
kind, have little influence in causing innocent neoplasms. Papilloma, 
fibroma, and singer's nodules are more frequent than lipoma, myxoma, 
and cysts. Gerhardt says he has never seen an adenoma, a chondroma, 
angioma, or a neuroma. Others, however, have reported adenoma in 
the larynx. Moritz Schmidt, in his work on Xewgrowths of the Upper 
(544 ) 



78 


256 


15 


46 


53 


109 





1 





3 





1 


22 


36 


6 


8 





3 


15 


76 


1 


2 



NEOPLASMS OF THE LARYNX 545 

Air Passages, gives the following table of laryngeal tumors seen in his 
clinic of 32,997 cases in ten years: 

Men. Women. 

Fibroma 178 

Papilloma 31 

Singer's nodules 56 

Lipoma 1 

Myxoma 3 

Fibromyxoma 1 

Tuberculous tumors 14 

Cysts 2 

Sarcoma 3 

Carcinoma 61 

Tracheal carcinoma 1 

This table is significant, and is contrary in some respects to the accepted 
opinion. For instance, in the above table, fibroma occurs more frequently 
than papilloma. He found 256 fibromata and only 46 papillomata. 
Singer's nodules occurred in 109 cases, hence both fibromata and 
singer's nodules (chorditis nodosa) were found more frequently than 
papillomata. The apparent discrepancy is, no doubt, in the differential 
diagnosis, which is often carelessly made. It is too often made without 
a microscopic examination, and is, therefore, often incorrect. 

The discussion concerning the exciting causes of benign neoplasms 
may be summarized as follows: 

The causes are (a) local and (b) constitutional. 

(a) Prominent among local causes is irritation. This produces hyper- 
emia and cell activity, hence the persistence and the exaggeration of 
these two conditions may endanger life by allowing the tumor to grow 
so large as to interfere with respiration, or they may assume malignant 
tendencies. Mouth breathing is an important factor in producing irrita- 
tion of the larynx. The required amount of moisture and warmth is 
not carried to the larynx, and the mucous membrane is overtaxed by 
the burden thrown upon it. The imperfectly prepared air causes a 
dryness as well as a hyperemia incident to the increased physiological 
activity of the mucosa, and the resultant irritation leads to an increased 
cellular activity. Under these conditions, the cellular arrangement is 
disturbed and neoplastic growths result. 

(b) Constitutional influences play an insignificant part in the etiology 
of innocent neoplasms. This does not take into consideration the specific 
constitutional dyscrasias, as syphilis and tuberculosis, which produce 
peculiar local laryngeal redundancies. 

In an adult, laryngeal papilloma is often associated with a warty skin, 
so much so that we can almost speak of a "warty diathesis." This 
theory was advanced by Fauvel, but it may be said, on the contrary, 
that the skin and the larynx have a totally different developmental origin. 
Sir Morrell Mackenzie maintained that syphilis and tuberculosis exer- 
cised a decidedly antagonistic influence to the development of new forma- 
tions. Lennox Browne did not share this view, his experience rather 
proving the reverse. Moritz Schmidt thinks that they favor new forma- 
35 



546 DISEASES OF THE LARYNX 

tions, because they always induce a low state of resistance or a local 
vulnerability. 

The Tendency to Malignancy.— It has been held that operative 
interference has a tendency to convert benign growths into malignant. 

This belief grew out of the fact that tumors which were operated upon 
and thought to be benign, were shown to be malignant in the recurrent 
state. Sir Felix Semon has shown that unoperated cases show even a 
greater percentage of converted malignancy than the ones which were 
operated upon. The following are his figures: 

In a total of 10,747 benign cases reported in the literature, 45 after- 
ward became malignant. They were divided as follows: 

In 8216 operated cases, 33, or 1 in 249, became malignant 

In 2531 non-operated cases, 12, or 1 in 211, became malignant. 

It is thus shown that a greater percentage of the non-operated cases 
become malignant. These figures should disprove the old theory that 
operative interference is an active factor in converting non-malignant 
neoplasms into the malignant variety. At the same time we must reckon 
the immense benefits which result from operations upon cases which 
do not become malignant, but continue to be troubled by the benign 
neoplasms. 

Neoplasms of the Subglottic Space. — Ferreri states, with reason, 
that subglottic polypi often cause greater obstruction to respiration 
than polypi of the supraglottic space. They do not, however, cause 
a change in the voice until they come in contact with the vocal 
cords, whereas, tumors of the supraglottic region cause it from the 
beginning. 

The development of subglottic polypi is insidious, hence they are not 
usually diagnosticated until well advanced, a fact which explains why 
they are usually larger than supraglottic polypi. 

The most common form of benign subglottic tumor is the fibroma. 
Myxoma does not occur quite so frequently, but it is not uncommon to 
find it associated with fibroma in the form of a myxofibroma. Ferreri 
also says that, exceptionally, cysts, chondromata, and circumscribed 
keratosis have been observed in the subglottic space. Papilloma is rarely 
found in the subglottic region. When present they are difficult to remove 
by the intralaryngeal route, except by direct laryngoscopy. Thyrotomy 
(laryngofissure) may therefore become necessary, or infrathyroid laryn- 
gotomy may be the chosen method of operation. 

The endolaryngeal methods of operating are with forceps, the snare, or 
the galvanocautery, either by direct or indirect laryngoscopy. Attacks 
of suffocation may render tracheotomy imperative, in which case the 
growth may be removed through the tracheal wound. 

Papilloma. — Etiology. — According to Jonathan Wright, this type of 
neoplasm occurs more frequently in the larynx than any other variety 
According to the table of Moritz Schmidt, fibroma occurs more fre- 
quently. They are closely related to various inflammatory growths 
which accompany syphilis, tuberculosis, and pachydermia. In view 
of this fact, many laryngologists regard chronic inflammation as an 



NEOPLASMS OF THE LARYNX 547 

etiological factor. As already stated under General Etiology, this is still 
a mooted question. According to Jonathan Wright, they are usually 
classified as papillary fibromata. This may account in part for the 
discrepancy between Schmidt and other writers. Schmidt may have 
classified as fibromata what others call papillary fibromata. Schmidt 
observed papilloma in about 9 per cent, of his cases, Schrotter in about 
IS per cent., and Moure in about 50 per cent. Schnitzler and Killian 
say they occur more frequently in children, and that fibromata occur 
more frequently in adults. Harmon Smith, J. Payson, C. Clark, Faurd, 
and Sir Morrell Mackenzie found them much less frequently in 
children. 

Symptoms. — Papillomata are usually attached to the anterior third 
of vocal cords, or at the anterior commissure, though they may spring 
from any portion of the larynx. Tuberculous papillomata often grow 
at the posterior commissure. 

Microscopically they have a stratified epithelial covering over a core of 
more or less vascular connective tissue. The outward growth of the 
epithelium is in contrast to the involuted growth of carcinoma. True 
nests or pearls of epithelial tissue have been found. 

Papilloma may appear upon inspection to be either pedunculated or 
sessile, though upon microscopic examination all varieties have the 
same structure. It is probable that those having a sessile or diffused base 
are in reality only numerous sessile pedunculated growths closely crowded 
together and fused in the process of development. When single, the 
growths may present a distinct pedicle with a warty growth at its ex- 
tremity. When multiple, it may appear to be sessile, or it may have 
the appearance of a cauliflower-like growth. 

Papillomata may be pale or congested; when congested they are more 
active in their growth. These appearances may be used for prognostic 
purposes. For example, when pale their activity is diminished and 
their removal is not so likely to be followed by recurrence, and vice 
versa. In one of the cases reported by Harmon Smith, there was a 
fibrosis at the anterior commissure of the cords, which Jonathan Wright 
thinks might disappear when the papillomata cease to recur. 

Like warts on the skin, papillomata of the larynx come and go without 
any apparent reason. J. Payson Clark emphasizes the importance of 
a physiological change which marks the limit of their growth. When 
this period occurs their removal may be accomplished with a reasonable 
hope of non-recurrence. He also emphasizes the futility of operating 
when they regrow immediately after operation; tracheotomy is then the 
rational mode of treatment. 

Hoarseness or aphonia are characteristic symptoms, though Logan 
Turner exhibited the larynx of a child crowded with papillomata, which 
died, without previous symptoms, during a choking fit at dinner. The 
hoarseness and aphonia may be transitory or constant. Dyspnea and 
cyanosis are sometimes severe, and when present, necessitate immediate 
tracheotomy. If the dyspnea is great, the supraclavicular region will 
be depressed. 



548 DISEASES OF THE LARYNX 

The general health is often impaired and the weight diminished by 
several pounds. 

Pathology. — Papillomata may be either hypertrophied normal papillae 
or they may be newgrowths. 

Prognosis. — According to J. Payson Clark, the prognosis during the 
retrogression stage, or stage of physiological limit, is quite favorable. 
This stage is also favorable for the removal of the growths. Conversely, 
during the stage of active growth, or before the stage of physiological 
limit, the prognosis is much less favorable either as to life or hope of 
cure by operation. Some cases get well without operative interference. 
According to Clark, the prognosis is influenced by the technique 
with which tracheotomy is performed. A preliminary tracheotomy per- 
formed at leisure and with exactness is more favorable than an emer- 
gency tracheotomy done in haste with poor technique. He therefore 
urges that a preliminary tracheotomy be performed when dyspnea 
first develops, and that the removal of the growths be delayed for several 
weeks, or until the growths begin to diminish in size. 

The prognosis is bad when the patient develops a cold or contracts 
measles or other infectious sequela?, especially if a tracheotomy tube is 
being worn. 

According to Harmon Smith, B. V. Burns collected statistics of 127 
children with laryngeal papillomata, of which 48 were not operated 
upon, and of these, 32 died, 28 by suffocation. Three were cured spon- 
taneously; 26 were tracheotomized, 7 died after operation. Twenty-one 
were subjected to laryngofissure, 8 being permanently cured. Forty 
were operated upon by the intralaryngeal route, and 13 were perma- 
nently cured. In Rosenberg's statistics of 109 children with papillomata 
subjected to laryngofissure, 20 died from suffocation due to recurrence 
of the growths. In 43 there was recurrence after repeated operations, 
though 40 were finally cured. 

The prognosis is much more favorable in adults. 

Treatment. — Local. — Delevan reports good results from the local 
application of alcohol in adults; Shurly from the use of thuja occiden- 
talis. Zinc chloride, nitrate of silver, adrenalin, and lactic acid have 
been tried with slight success. 

Internal. — Of the internal remedies, arsenic has produced the best 
results. Bostoc favors the use of potassium iodide. The value of these 
remedies seems to depend upon their regenerating effect upon the general 
system. 

Surgical. — The trend of opinion is away from laryngofissure (thy- 
rotomy) and the indirect laryngeal method, and toward tracheotomy 
and the direct laryngeal method. 

Laryngo fissure is not favored on account of the frequent recurrence 
of the growths. The operation is attended with shock, possibly by death, 
and is somewhat disfiguring. It is often attended with stenosis of the 
larynx and an impairment of the voice. The chief argument against 
this operation for laryngeal papilloma is that other methods afford a 
better means of relief. 



OPERATION BY INDIRECT LARYNGOSCOPY 549 

Operation by direct laryngoscopy (Chapter XXXI) with Jackson's 
self-illuminated tube spatula is much superior to indirect laryngoscopy. 
The growths are brought into clearer vision and greater accessibility. 
Removal by direct laryngoscopy may be attempted when dyspnea and 
cyanosis are not present. If these symptoms are present, the instru- 
ments for tracheotomy should be in readiness if suffocation occur. The 
growths may be removed through Jackon's self-illuminated tube spatula 
with straight forceps. 

Operation by indirect laryngoscopy may be practised when symptoms 
of suffocation are absent and Jackson's or Killian's tube spatula is not 
at hand. The surgeon should, however, be prepared to perform trache- 
otomy if suffocation threatens during the operation. 

Tracheotomy should be performed in all cases in which dyspnea and 
cyanosis are present. The procedure should not be postponed until it 
becomes an imperative measure, but should be done while the patient 
is still in a condition to permit the operator to do it with deliberation 
and good technique, as suggested by J. Pay son Clark. According to 
G. Hunter Mackenzie, tracheotomy is sometimes followed by a cure of 
the papillomata. While this is true of some cases, it is not true of all, 
nor of the majority of cases. Tracheotomy should be done to avoid 
the dangers of suffocation, aside from its curative influence. It should 
rarely be followed by the immediate removal of the growths. Weeks 
or months should usually intervene. Indeed, it is useless to remove the 
growths while they are in the active stage, as they will recur, often in 
greater abundance, than before their removal. Indeed, if the healthy 
tissue is injured during the operation, the growth will often promptly 
appear at this point (H. L. Swain). 

When the growths show a state of quiescence or of retrogression, 
they may be removed by indirect or direct laryngoscopy or through 
the tracheal wound. 



OPERATION BY INDIRECT LARYNGOSCOPY 

In describing this operation for the removal of papilloma, it must be 
taken as a type of surgical procedure used in the removal of nearly all 
varieties of benign laryngeal neoplasms. Each case will, of course, 
require some modification of the various steps in the operation. 

Technique.— Preparation of the Patient.— (a) The throat should be 
gently sprayed with Seiler's or Dobel's solution. The fauces and the 
larynx should then be sprayed with a 2 per cent, solution of cocaine to 
reduce the reflex irritability. 

(6) The larynx is then swabbed with a 10 per cent, solution of cocaine. 
This should be repeated at intervals of five minutes until anesthesia is 
induced. If this does not produce anesthesia after several applications, 
one or two applications of a 20 per cent, solution should be made. This 
strength of solution should be used sparingly and with caution, although 
in my experience the larynx has been quite tolerant of cocaine. 



550 



DISEASES OF THE LARYNX 



(c) The laryngoscopic mirror is introduced into the oropharynx with 
its reflecting surface directed downward and forward so as to reflect the 
rays of light from the head mirror to the growth, the tongue being gently 



Fig. 332 




Krauss-Heryng laryngeal forceps. 



Fig. 333 



rolled forward on the forefinger of the 
left hand. The epiglottis is thereby 
lifted, exposing the larynx to view. 

(d) Next introduce the curved 
laryngeal pincette, or double cutting 
forceps (Fig. 332), into the upper 
space of the larynx until its cutting 
extremity touches the growth (Fig. 
333). It must be borne in mind that 
the image in the mirror is reversed, 
hence the movements of the instru- 
ment should be directed in an exactly 
opposite direction from what appears 
to be necessary according to the image 
in the mirror. For example, if the tip 
of the instrument seems to need a 
more forward position, so manipulate 
the handle as to move the tip back- 
ward, i. e., lower the handle. If the 
tip of the instrument seems to be too 
near the posterior portion of the 
image, it is in reality too near the 
anterior portion. A little practice 
upon a model or upon a patient will 
familiarize the student with this 
procedure. The surgeon soon learns 
intuitively to move the instrument 
in the proper direction. 
It is of great aid first to fix firmly in the mind the anatomical relations 
of the various parts of the larynx. For example, it must be remembered 




Detailed drawing showing the laryngeal 
forceps placed to remove the neoplasm. 



MALIGNANT NEOPLASMS OF THE LARYNX 551 

that the epiglottis stands at the anterior commissure of the larynx, and 
the arytenoid prominences at the posterior commissure. These simple 
anatomical guides, if impressed upon the memory of the operator, will 
lead him unconsciously to guide the laryngeal instrument in the proper 
direction. 

(e) Having located the growth with the laryngeal forceps or pincette, 
so manipulate the handle of the instrument as to separate the tips, and 
then with a slight downward movement of the instrument close the for- 
ceps upon the neoplasm and remove it en masse or in part. If the growth 
is large or multiple, several repetitions of the foregoing procedure may 
be required. The growth should be removed with as little trauma to 
the surrounding tissues as possible. 

OPERATION BY DIRECT LARYNGOSCOPY 

(See Direct Laryngoscopy, Chapter XXXI) 

MALIGNANT NEOPLASMS OF THE LARYNX 

The Lymphatic Drainage of the Larynx. — The lymphatics of the 
larynx are of clinical importance in malignant neoplasms and infectious 
diseases of the larynx. According to Most, Cunes, Boubland, and 
Green, the following summary gives the essential facts: 

The lymphatic trunks which take their source from the larynx are 
derived from a network of radicles which extend throughout the larynx 
beneath the mucous membrane. This network is divided by a hori- 
zontal plane at the level of the vocal cords into a supraglottic and an 
infraglottic portion. The supraglottic portion includes the lymphatics 
of the epiglottis, arytenoids, ventricular bands, ventricles, and vocal cords. 
The network of vessels is continuous throughout these areas. Over 
the upper portion and posterior surface of the epiglottis the network is 
fine and the meshes are far apart. In front and lower down, especially 
at the sides, the meshwork is denser and the strands thicker. Over the 
arytenoids, ventricular bands, and throughout the ventricular pouches 
the lymph channels are thick and closely woven. In the vocal cords, 
however, the network is very fine and more sparse than in any other part 
of the larynx. The infraglottic network is finer than that above the 
vocal cords, but by no means as fine as that of the cords themselves. 
The lymph from these radicles is collected into trunks which leave the 
laryngeal cavity at certain definite places. 

In the upper part of the larynx the only place of egress is through the 
thyrohyoid membrane. The lymph vessels of the upper network as- 
semble in the vicinity of the aryepiglottic folds into several trunks, three 
to six in number, which leave the larynx through the above-mentioned 
membrane near the superior thyroid artery, a corresponding group 
being on either side of the larynx. 

These trunks course outward and backward, more or less in relation 
to the superior thyroid artery, to the carotid region, and terminate in 



552 



DISEASES OF THE LARYNX 



Fig. 334 



nodes which lie along the surface of the internal jugular vein at the 
level of the bifurcation of the carotid. The upper trunk of this group 
often runs backward, after emerging from the thyrohyoid membrane, 
along the hyoid bone to the tip of the lesser cornu, and thence outward 
to a node lying on the inferior aspect of the posterior belly of the digastric 
muscle. The lower trunks of this group may run by a lower course, 
outward and downward, into glands in the chain lying on the surface 
of the internal jugular vein, below the lower border of the lateral lobe 
of the thyroid gland (Fig. 334). 

The collecting trunks of the infraglottic network are divided into an 
anterior and a posterior division. The anterior division consists of three 
or four small trunks, which pierce the cricothyroid membrane in the 

median line and terminate in small 
glands, which lie in the median line 
at uncertain locations. The up- 
permost of these is fairly constant 
and lies in the V-shaped space of 
the cricothyroid membrane formed 
by the inner borders of two thy- 
roid isthmuses, and a third on the 
anterior surface of the trachea. 
These two are denominated re- 
spectively the prethyroid and the 
pretracheal glands. They may 
receive trunks from the anterior 
infraglottic group. Efferent trunks 
from these glands run to the be- 
forementioned chain of glands 
lying on the anterior external sur- 
face of the internal jugular vein. 

In the posterior division are three 
to five infraglottic collecting trunks, 
which penetrate the cricotracheal 
membrane at or near the line of 
junction of the cartilaginous and 
membranous portions of the trachea 
and run into a chain of glands, two or five in number, which lie along the 
course of the recurrent laryngeal nerve known as the recurrent chain. 
From these glands run vessels communicating with the lowermost glands 
of the internal jugular chain and a few to the supraclavicular group of 
glands. 

The lymphatic drainage from all parts of the larynx thus eventually 
leads into the chain of glands lying under the sternomastoid muscle, 
along the surface of the internal jugular vein, or into the supraclavicular 
glands. The prelaryngeal, prethyroid, and pretracheal glands are 
merely intercepters of the current on its way to the deeper glands. 

The spread of infection or of malignant neoplasms from either the 
supracordal (glottic) or infracordal region is to the deep lymphatic 




Schema of the lymphatic flow from the supra- 
glottic and the infraglottic regions of the larynx. 
The glands of the supraglottic region flow into 
the posterior chain, while the infraglottic glands 
flow into the anterior cervical chain of glands. 
This is of diagnostic significance in determining 
if a cancer is supraglottic or infraglottic. 



MALIGNANT NEOPLASMS OF THE LARYNX 553 

nodes along the internal jugular vein beneath the sternomastoid muscle, 
or, in other words, to the same lymphatic system into which the tonsils 
drain. In infectious and advanced malignant processes of the larynx 
the deep cervical glands along the internal jugular vein and beneath the 
sternomastoid muscles are enlarged. In malignant tumors of the larynx 
such enlargement of the glands constitute a contra-indication to opera- 
tive interference. 

Varieties. — Epithelioma, adenocarcinoma, and sarcoma. Of these 
the epithelioma occurs the most frequently. Ziemssen reported 57 
epitheliomata in 68 malignant cases, while 9 were sarcomata. Bos- 
worth collected 344 cases, of which 204 were carcinomata and 130 sar- 
comata. Sir Felix Semon, in 1899, gathered the statistics of all laryngeal 
growths, amounting, all told, to 10,747 non-malignant cases and 1550 
malignant cases, 1 in 7 being malignant. 

General Facts. — It may be stated, with some confidence, that malig- 
nant neoplasms may be cured if operated upon sufficiently early. This 
is not done as often as it should be, hence the mortality rate is still 
extremely high. The crying need of the hour is "an early diagnosis." 
How sad the comment upon medical attainments is the "fact" that but 
few practitioners are able to diagnosticate laryngeal cancer until the 
patient is in extremis. Yet how easy it is to learn one or two simple 
indications that should at least put them on their guard, and save their 
self-respect, their reputation, and the lives of their patients. 

What, then, are the early indications of laryngeal cancer? The early 
signs of cancer of the larynx are: 

(a) Continued hoarseness without cough, and without other known 
cause. 

(b) Sharp, sudden pains in the larynx, the ear, or the pharynx. 

(c) Age, the fortieth year and upward; though cancer, especially 
sarcoma, may occur at a much younger age. 

(d) A laryngoscopic examination may show loss of movement of one 
of the vocal cords. 

The above symptoms are not conclusive, but they should arouse 
suspicion of malignancy. The practitioner may, upon the foregoing 
data, make a tentative diagnosis of a malignant growth in the larynx; 
and he will be correct in nearly every instance. 

To sum up: If a patient, forty or more years old, complains of con- 
tinued hoarseness without cough, and of sharp, sudden pains through 
the larynx, pharynx, or ear, he should be suspected of having a malignant 
growth in the larynx. 

What other diseases cause this symptom-complex f Perhaps laryngeal 
tuberculosis, syphilis, perichondritis, or rheumatic laryngitis may approx- 
imately duplicate it. There are other peculiar symptoms of these dis- 
eases, however, which readily distinguish them from malignant neoplasms 
In rheumatism there may be sharp pains and hoarseness, but the symp- 
toms are fugitive; they do not persist as in malignant neoplasms. In 
tuberculosis and syphilis a casual examination should readily enable 
the practitioner to make the differentiation. 



554 DISEASES OF THE LARYNX 

The extreme simplicity of the symptom complex of the early stage of 
malignant growth of the larynx encourages me to emphasize the symp- 
toms, as I have in the preceding paragraphs. I wish to urge every practi- 
tioner of medicine and surgery to impress indelibly upon his mind the 
few facts just given. Cancer of the larynx is not a rare disease, but, on 
the contrary, is quite common; more than 1500 cases were on record in 
1889, and since then as many more have been diagnosticated and treated, 
though many ha\e not been published. Inasmuch, therefore, as the dis- 
ease is comparatively common, I desire to make plain the tentative 
diagnosis, and divest it all of complex considerations. It may be reduced 
to (a) age, forty years or more; (6) continued hoarseness without cough; 
and (c) sudden, sharp pains in the larynx, pharynx, or ears. 

Etiology. — The exciting cause of malignant neoplasms of the larynx 
is not clearly understood. Chronic inflammation of the larynx seems 
to be a factor, as the statistics show that families having a history of 
malignant growths are more often attacked in the larynx when subject 
to chronic inflammations. The use of tobacco also seems to be an 
exciting cause. 

Virchow tersely says that healthy tissues, if continually subjected to 
irritations, may be the seat of heteroplastic growths, and that the larynx, 
more than any other organ, where no trace of heredity or predisposition 
exists, is likely to be the site of malignant growths. 

Age. — The age at which malignant growths of the larynx appear 
varies somewhat with the variety of the cancer. Sarcoma often occurs 
in the very young. The author saw a case of melanosarcoma in a child 
eighteen months old, which pursued a very rapid course with a fatal 
termination. It is, however, more frequent in young adult life. Epi- 
thelioma occurs in middle adult life and in old age; carcinoma, chiefly 
between the ages of forty and sixty. 

Malignant growths of the larynx, without reference to their variety, 
according to the following table from Gerhardt, occur with greatest 
frequency between the fiftieth and sixtieth years: 

Cases. 

20 to 30 4 

30 to 40 18 

40 to 50 49 

50 to 60 . . 76 

60 to 70 30 

70 to 80 . , . 10 

Total . . - 187 

Schrotter observed carcinoma in a child aged three and one-half years, 
and in a girl aged ten and one-half years. 

Sex. — Sex influences the formation of malignant growths to a marked 
degree. Gerhardt found carcinoma three times as prevalent in males 
as in females, while Semon found them in males four times as frequently. 

Social Standing. — The conditions in life seem to influence the occur- 
rence of malignant growths of the larynx, the well-to-do being more 
often afflicted than the poor. 



MALIGNANT NEOPLASMS OF THE LARYNX 555 

Pathology. — The pathological anatomy of laryngeal cancers is quite 
similar to that of carcinoma and sarcoma elsewhere in the body, and 
will not be described in detail. Under Symptoms will be found a brief 
characterization of malignant epithelial neoplasms, to which the reader 
is referred. 

Symptoms. — The chief clinical symptoms are: (a) Continued hoarse- 
ness without other known cause, (b) Sharp lancinating pains in the 
ear and pharynx, (c) Loss of movement of the vocal cord on the affected 
side, (d) The patient is forty years of age, or more, except in sarcoma, 
which may occur at any age. 

Continued hoarseness may be the only symptom for several months, 
and the pain and the loss of movement of the cord may commence at a 
later period; hence, continued hoarseness, without other known cause, 
should, in a patient forty or more years of age, be sufficient to arouse 
suspicions as to the presence of a malignant growth in the larynx. While 
it may be said that a positive early diagnosis is difficult to make, it is, on 
the other hand, easy to make a provisional diagnosis and place the patient 
under observation so as to give him the advantage of the earliest possible 
diagnosis. I make a plea, therefore, with Sir Felix Semon, von Bergmann, 
Chevalier Jackson, Otto Stein, and others for an early diagnosis. This 
alone offers a reasonable hope for the successful treatment of this 
disease. 

The hoarseness grows progressively worse, and the voice may finally 
become aphonic. 

As the edema develops, and the growth encroaches upon the lumen 
of the glottis, dyspnea, of greater or less intensity, may embarrass the 
patient. 

Cough, increasing with the progress of the disease, is usually present. 
The expectoration is at first similar to that in chronic laryngitis, and 
later is admixed with purulent secretion, and with blood in the ulcerative 
stage. 

Dysphagia, or difficult deglutition, is a late symptom in the intrinsic 
variety of the disease. If, however, the primary cancer is in the pharynx 
or the esophagus, it may appear at a much earlier period. 

The enlargement of the lymphatic glands of the neck is a late symp- 
tom, only occurring after ulceration of the tumor has taken place. Epi- 
thelioma is often attended with a very tardy enlargement of the glands. 
In intrinsic tumors of the larynx two sets of glands are secondarily 
affected, namely, the group at the angle of the jaw and those behind 
the sternocleidomastoid muscle. The subglottic glands of the larynx 
empty into those at the angle of the jaw, while the supraglottic glands 
empty into those posterior to the sternocleidomastoid muscle. If, there- 
fore, the glands at the angle of the jaw are enlarged, it should arouse 
suspicion, at least, of a subglottic cancer. 

The late involvement of the lymphatic glands in intrinsic laryngeal 
cancer is another argument in favor of an early diagnosis, as the tumor 
can then be easily removed in toto. Should the diagnosis be made only 
after glandular enlargement has taken place, the operation is a much 



556 



DISEASES OF THE LARYNX 



more formidable one, as it necessitates the removal of the glands. Fur- 
thermore, the probability of total resection of either tumor or glands is 
generally lessened in the advanced stage of the disease, for recurrence 
generally takes place. 

Laryngoscopy. — The laryngoscopic examination often presents a 
picture so characteristic as to confirm at once the suspicion aroused by 
the other symptoms present. When only one side is affected, the abduc- 
tors, and later the adductors, are paralyzed on the affected side. Both 
sides are paralyzed when the entire larynx is involved. 

According to Semon's law, the abductor muscles atrophy before the 
adductor fibers, hence abductor paralysis appears first and is followed 
by adductor paralysis. 

By reference to Figs. 335 and 336, illustrating two of the author's 
cases, the laryngeal image in unilateral cancer of the larynx is shown. 



Fig. 335 



Fig. 336 





Carcinoma of the right ventricular band of 
the larynx. It was removed by the intralaryn- 
geal route by the author, returned in one year, 
was reoperated upon by the same route with- 
out relief, the patient dying two months later. 
(Author's case.) 



Paralysis of the thyro-arytenoidei interni 
and the arytenoideus in attempted phonation, 
more severe on the left side. Drawn from 
the author's case of subglottic carcinoma of 
the larynx. 



The microscopic diagnosis is not always reliable, especially if the 
tissue is removed by the endolaryngeal route (W. J. Terry), as the can- 
cerous growth may be deeply seated beneath the mucous membrane. 
If, however, the specimen for examination is removed by laryngofissure, 
it can be obtained from the deeper structures, and should, therefore, 
afford an accurate means of diagnosis. B. Fraenkel maintains that the 
microscopic diagnosis is of fundamental importance. Negative results 
should not, however, be taken as final, especially if the specimen is 
obtained by the endolaryngeal route. A positive finding, however, is 
dependable if made by a competent pathologist. A globular collection 
of epithelial cells is suspicious only. Epithelial cells must be found 
where they do not belong. The irregular structure of the epithelium, 
such as is found in typical epithelial nests, is characteristic of cancer. 

When the microscopic findings include the foregoing points, a positive 
diagnosis of cancer of the epithelial variety may be made. 



MALIGNANT NEOPLASMS OF THE LARYNX 557 

Diagnosis. — Cancer of the larynx should be differentiated from (a) 
chronic laryngitis, (b) syphilitic laryngitis, (c) tuberculous laryngitis, 
(d) perichondritis, and (e) benign neoplasms of the larynx. 

(a) Chronic laryngitis: hoarseness, while present in both chronic 
laryngitis and carcinoma, is more persistent in carcinoma. In chronic 
laryngitis the voice is husky upon arising, but becomes clear during the 
day, and in the hypertrophic variety there are discrete enlargements of 
the mucosa, but they do not have the distinct nodular surface which 
is present in carcinoma. In chronic laryngitis the vocal cords are freely 
movable in both abduction and adduction, whereas in carcinoma one 
or both cords are immovable. 

(b) In syphilitic laryngitis, the hoarseness is low-pitched, and brassy 
or raucous in character. In carcinoma of the larynx it is higher pitched, 
and softer in character; indeed, it may become aphonic in the later stages. 
The cords are freely movable in syphilitic laryngitis, and the history of 
the case usually clears the diagnosis. 

(c) Tuberculous laryngitis is characterized by hoarseness and pain, 
and when perichondritis is present, by fixation of one or both vocal 
cords. The history and the examination of the sputum render the 
diagnosis so clear that malignancy is practically excluded. 

(d) Benign neoplasms of the vocal cords (the most frequent site of 
intrinsic malignant neoplasm) are characterized by hoarseness, though 
pain and paralysis of the laryngeal muscles are absent. 

Prognosis. — The general prognosis of malignant growths of the larynx 
is bad. This would not be so if an earlier diagnosis were made. In 
other words, the prognosis depends in a large measure upon the early 
recognition and surgical removal of the diseased tissue. Sir Felix Semon 
claims that 90 per cent, of his cases have been cured by thyrotomy. All, 
or nearly all, of his surgical cases were diagnosticated and operated upon 
in the early stage, hence the high percentage of cures. Jackson, in a 
total of 9 complete laryngectomies, including the epiglottis, had but 1 
death immediately following the operation. The other cases lived eight 
or more months after the operations. 

Gluck in his first 10 cases reported 2 as cured (three years without 
recurrence). In his last series of 22 cases 1 died, making a percentage 
of recoveries higher than Semon's. Of a total of 23 complete laryn- 
gectomies, he claims 3 good results. In 1903, out of 125 cases he claimed 
he could show 38 living cases, the oldest still alive and in good condition 
thirteen years after the operation. 

Of those dead, some lived eleven, eight, six and one-half, five and 
one-half, four and one-half, and three and one-half years. Some died 
of illness other than recurrence. 

Kocher in 12 cases had 6 recurrences. White and Powers, after 
reviewing a large number of cases, conclude that in complete laryngec- 
tomies the death rate is 35 per cent., while in partial laryngectomies it 
is about 27 per cent. 

Werckmeister collected 297 cases of complete laryngectomy, of which 
36 were fatal, by which he probably means that 36 died during or soon 



558 DISEASES OF THE LARYNX 

after the operations. How many died later from recurrence is probably 
not shown in these figures. 

In a collection of 105 cases operated on by laryngofissure, 4 died of 
pneumonia within eight days. The low death rate from this cause stamps 
the procedure as safe from a surgical standpoint. The voice after laryn- 
gofissure varied with the extent of the operation. In benign tumors it 
usually remains fair or good. In malignant neoplasms, as they generally 
affect the integrity of one or both cords, it is not so good. If only one 
cord is involved, a useful voice is retained in simple laryngofissure and 
in hemilaryngectomy. 

In summing up the prognosis under operative treatment, it may be 
said: (a) That in those cases diagnosticated and operated on in the early 
stage, before ulceration and extension to the neighboring parts, the 
prognosis is good, (b) In those cases operated on in the late stages the 
prognosis is bad. (c) The personality of the operator and the fortunate 
opportunity of seeing the cases in an early stage favor a better prognosis. 
(d) Laryngofissure gives a better chance of recovery when the disease has 
not extended to the extrinsic parts of the larynx, (e) Total laryngectomy is 
attended with greater shock and a higher mortality than the more limited 
operations. It should be remembered, however, that this method of 
operating is usually adopted in the more advanced and hopeless cases. 
(f) Keishaber has divided cancer of the larynx into two clinical groups, 
which, from the standpoint of prognosis and treatment, is important, 
namely: (1) Intrinsic cancer of the larynx, and (2) extrinsic cancer of 
the larynx Intrinsic cancer has its origin in the vocal cords, the 
ventricular bands, and the ventricular pouches. Extrinsic cancer of the 
larynx arises from the arytenoid cartilages, the epiglottis, and other 
parts contiguous to the larynx. In intrinsic cancer the growth develops 
slowly and extends with extreme reluctance by metastasis to the lymph 
glands behind the sternocleidomastoid and to the neighboring tissues 
surrounding the larynx. 

In the extrinsic variety, the reverse of the above facts is true. In 
other words, the prognosis in intrinsic cancer of the larynx is naturally 
much more favorable than it is in the extrinsic variety. To make accurate 
deductions from the statistics of cancer of the larynx, it is necessary 
to know whether it is intrinsic or extrinsic, sarcomatous (for it is much 
more favorable in this variety) or carcinomatous; whether operated in 
the early, middle, or late stage; whether by laryngofissure, partial laryn- 
gectomy, hemilaryngectomy, complete laryngectomy, or by ligation and 
resection of the external carotid arteries and their branches, as advo- 
cated by Dawbarn. 

The foregoing data fairly represents the prognosis under existing 
methods and conditions, though I fear that it presents it in a too favor- 
able light. 

Frank Hartly, in 1902, reviewed the literature from 1833, when Brauers 
performed the first thyrotomy, and the first laryngectomy by Watson 
in 1878, down to the more improved methods of operating in 1900. The 
death rate within the first days after the operation, up to 1889, for laryn- 



MALIGNANT NEOPLASMS OF THE LARYNX 559 

gectomies was 44 per cent., and of those remaining cured for three 
years prior to 1SS9 it was 7 per cent. Since 1889 the death rate within 
the first ten days has been 8.5 per cent.; in those remaining cured, 15 
per cent. The following tabulation shows the improvement in the 
immediate and the remote death rate and the net gain in the mortality: 



Death Rate in Laryngectomies for Every One Hundred Operatio 



xs. 



Immediate deaths. Remote deaths. Total deaths. Living. 

Per cent. Per cent. Per cent. Per cent. 

Prior to 1889 44.0 52.0 96.0 4.0 

1889 to 1900 8.5 47.5 56.5 44.0 

The present total death rate before the end of the third year is 56 
per cent., as against 96 per cent, prior to 1889. The tremendous im- 
provement in the mortality rate is encouraging, and stands as the strongest 
argument in favor of still further improving the surgical technique for 
the cure of this dread disease. It should be remembered, however, 
that the improved mortality rate following the surgical treatment is 
largely due to the more intelligent selection of cases, as well as to the 
improved technique and asepsis now in vogue. In the period prior to 
1889 the failure to elect the proper method of operating probably largely 
contributed to the high death rate. There is still room for improve- 
ment in this regard, and it is to be hoped that in the near future a still 
lessened mortuary report will be given. 

Pean reports a case of extirpation of the larynx and part of the esopha- 
gus for a cancerous tumor diagnosticated by laryngoscopic examination. 
Although apparently limited to the left side, it was found to extend to 
the right side, and to the upper portion of the esophagus, the hyoid bone, 
and the base of the tongue. The whole mass was removed, and, to com- 
pensate for the extensive loss of substance, the esophagus was drawn up 
and stitched to the skin in the upper angle of the wound. The trachea 
with a cannula inserted in it was also secured by suture to the skin. An 
artificial larynx was supplied, which not only enabled the patient to 
swallow, but also allowed him to inhale air physiologically prepared in 
passing through the nose. 

Pean draws the following conclusions from the case: 

1. That it is impossible, prior to operation, to be certain of the extent 
of the disease when no subjective symptoms are present. 

2. That the surgeon must never promise beforehand to limit the opera- 
tion to the removal of only a part of the larynx. 

3. That an extensive operation, including the removal of the hyoid bone 
and the base of the tongue, may be undertaken with safety and success. 

4. That after such operation, important modifications of the anatomy 
of the parts operated on always follow, the abnormal openings of the 
trachea and the esophagus being raised, the epiglottis and the root of 
the tongue being lowered. 

5. That, thanks to suitable mechanical appliances, the functions of 
the parts can be, to a large extent, restored, even after the most extensive 
operations. 



560 DISEASES OF THE LARYNX 

Treatment. — The various methods of treating laryngeal cancer may 
be appropriately studied under the following heads: 

1. The endolaryngeal operation. 

2. Laryngofissure or thyrotomy. 

3. Subhyoid pharyngotomy. 

4. Partial laryngectomy or hemilaryngectomy. 

5. Complete laryngectomy. 

6. Ligation or injection of the external carotids and their branches. 

7. Tracheotomy. 

Each of the foregoing methods of treatment has its advocates, and, in 
selected cases, its advantages. I shall endeavor to point out the most 
prominent indications for each in such a way as to enable the surgeon 
to elect the one most suitable for the case in hand. 

1. The Endolaryngeal Operation. — The endolaryngeal operation for 
cancer of the larynx is not unlike that described for papilloma of the 
larynx. The responsibility attending it is, of course, much greater on 
account of the gravity of the disease. The most distinguished advocate 
of this method of operating is B. Fraenkel, who cured three cases by 
operating on them by the endolaryngeal route at intervals covering a 
period of five years. At the time of his published report there had 
been no recurrence after two years of quiescence. I have operated on 
a few cases by this method, in one of which there was recurrence in ten 
months, with pronounced hoarseness, dyspnea, pain, and cachexia. 
The second operation did not relieve the patient as did the first. He 
gradually grew worse, and died two months after the second operation, 
which was performed twelve months after the first. The case (Fig. 337) 
should have been subjected to hemilaryngectomy or complete laryn- 
gectomy at the time of the first operation, notwithstanding the fact 
that the tumor was apparently accessible to the double cutting forceps 
via the mouth. It is quite probable that I did not succeed in removing 
all the cancerous tissue, which I could have done had I resorted to an 
operation by the external route. Notwithstanding the brilliant results 
reported by B. Fraenkel, I think the endolaryngeal operation should 
rarely be the operation of choice. It may be chosen when other methods 
are refused. Direct laryngoscopy promises better results than are 
obtained by the indirect method. Laryngofissure may be performed, if a 
pathologist be present in order to make an examination of the specimen 
by the freezing method, which only requires a few minutes. In Figs. 332 
and 333 are shown the author's cases of pedunculated carcinoma of the 
larynx. This is a rare condition, and I know of only two similar cases 
on record (B. Fraenkel). The glands of the neck were large and firm. 
A gland was first removed and submitted to microscopic examination 
and carcinoma was found. The laryngeal neoplasm was then removed 
with a snare. As the patient swallowed the growth, warm salted water 
was given and the tumor ejected. The patient, aged forty-five years, 
died eighteen months later, metastatic carcinomata being found post- 
mortem in the liver, spleen, and stomach. 

The operation may be completed by the method which appears to be 



MALIGNANT NEOPLASMS OF THE LARYNX 



561 



best in view of the macroscopic and microscopic findings. The precise 
location and extent of the growth, whether intrinsic or extrinsic, should 
also be determined after the larynx is opened by laryngofissure. 

In order to render the thorough examination of the parts through the 
laryngofissure possible, the interior of the larynx should be brushed or 
sprayed with a 10 per cent, solution of cocaine to abolish the reflexes. 
Adrenalin, 1 to 1000, may be used to shrink the mucous membrane, and 
thus bring the limitations of the growth into greater prominence. 



Fig. 337 



Fig. 338 





The author's case of pedunculated carci- 
noma of the larynx growing from the left 
ventricular band. The tumor was distinctly 
movable. It was removed with a cold- wire 
snare through the mouth. The patient swal- 
lowed it, was given warm salt solution, after 
which he ejected it, and the rare specimen was 
thus preserved. A gland was previously re- 
moved from the corresponding side of the 
neck, and upon microscopic examination by 
the Columbus laboratories, it was pronounced 
carcinoma. The laryngeal tumor was likewise 
submitted and pronounced carcinoma. Peculiar 
interest attends the case on account of the 
distinct segregation of the tumor from the sur- 
rounding tissues and its pedicled attachment. 



View of the inferior surface of the author's 
case of pedunculated carcinoma of the larynx 
in a man aged forty-five years. The peduncle 
was tubular and composed of mucous mem- 
brane, and was attached to the ventricular 
band of the left side. The tumor was freely 
movable in the larynx, occasionally obstruct- 
ing the breathing. The tumor presented the 
appearances of a gland dislocated beneath the 
mucous membrane. 



2. Laryngofissure or Thyrotomy. — This operation is one that should 
be chosen for the purpose of obtaining a specimen for examination and 
for the removal of cancerous and benign growths. 

The indications: (a) For the removal of foreign bodies lodged in the 
ventricular pouch which cannot be removed by either the direct or 
indirect endolaryngeal route. 

(b) For the removal of benign neoplasms which cannot be reached 
successfully by the endolaryngeal route. 

(c) To obtain a specimen from a suspected malignant neoplasm of 
the larynx, for microscopic examination, especially when the one re- 
moved by the endolaryngeal route gives a negative result. 

36 



562 DISEASES OF THE LARYNX 

(d) To expose the interior of the larynx to view in order to determine 
the gross appearance, site, and extent of a laryngeal neoplasm, pre- 
liminary to the election of the method of removal. 

(e) As a method of election for the removal of an intrinsic malignant 
growth of the larynx. 

When should laryngofissure he the method of choice or election in malig- 
nant neoplasms? 

(J) When, upon larvngoscopic examination, the growth is found to be 
limited to the soft parts or to a small area, and can be removed through 
the larvngofissure, with the sacrifice of but little or none of the carti- 
laginous framework of the larynx. 

(g) When, upon larvngoscopic examination, the growth, while some- 
what extensive, does not appear to involve the deeper tissues, and can in 
all probability be entirely removed by laryngofissure. 

(h) When the growth is somewhat more extensive than in (J) and 
(g), but is still circumscribed within a fractional part or one-half of the 
larynx, having its origin from one cord, or the ventricular pouch or band 
is not ulcerated, and there is no enlargement of the glands posterior to the 
sernocleidomastoid muscle. 

(i) When the growth is intrinsic, the vocal cord, the ventricular pouch, 
or the ventricular band, even though it is quite large, and the lymphatic 
glands posterior to the sternocleidomastoid muscle are not enlarged, it 
is barely possible that operation by laryngofissure may be successfully 
done. If the growth has involved the cartilaginous framework of the 
larynx to such an extent as to necessitate the removal of a considerable 
portion of it" on one side, laryngofissure should not be the method of 
choice. Hemilaryngectomy or incomplete laryngectomy should be 
chosen after a preliminary laryngofissure. 

Axiom: Laryngofissure should be the operation of choice when the 
malignant neoplasm is intrinsic, and when diagnosticated in the earlv 
stage. 

Laryngofissure or thyrotomy has been frequently referred to as a 
method of removing growths, foreign bodies, and stenosis of the larynx. 
It will be described as such, and cross-reference will be made to it 
wherever the author thinks it the proper procedure for other affections. 

Technique. — This operation consists in splitting the larynx in the 
anterior median line and removing the growth through the fissure thus 
made. It is not a formidable procedure, and should be done much 
oftener than it is. 

(a) Preparation of the patient: In this, as in all cases where a gen- 
eral anesthetic is to be administered, the patient should be placed in a 
hospital twenty-four to forty-eight hours before the time of operation. 
Broken doses of calomel, followed by a saline cathartic the following 
morning, should be administered in time to produce a free evacuation of 
the bowels a few hours before the operation. The patient should be 
given no food within nine hours of the operation. 

(b) The preparation of the field of operation: The neck should be 
cleansed and shaved twelve hours prior to the operation, and a moist 



MALIGNANT NEOPLASMS OF THE LARYNX 



563 



Fig. 339 




carbolic dressing placed over the laryngeal region and held in position 
with a bandage. The cleansing should be repeated after the patient is 
under the influence of the anesthetic. 

(c) Anesthesia: Rectal anesthesia, as practised by Cunningham, of 
Boston, and Stucky, of Lexington, is performed by the administration of 
the vapor of ether with Cunning- 
ham's apparatus. It combines sim- 
plicity and safety; a small amount 
of ether is used; and its administra- 
tion is not followed by nausea or 
vomiting, though prolonged diar- 
rhea may be produced. The 
method is especially useful in 
operations about the head, as the 
anesthetist is removed from the 
field of operation. In throat opera- 
tions it is especially recommended, 
as the anesthesia may be admin- 
istered throughout the operation 
and the secretions are not stimu- 
lated thereby. 

(d) Cutaneous incision: The 
incision should be made in the 
anterior median line, and should 
extend from the os hyoides above 
to the sternoclavicular notch below 
(Fig. 339). There are but few structures of importance which are en- 
countered in this region, excepting a small amount of areolar tissue 
and the anastomosis of the inferior laryngeal arteries in the median 
line. These arteries are encountered at either the inferior border of the 
thyroid cartilage or the superior border of the cricoid cartilage, hence 
it may not be necessary to cut them, as they can be pushed aside. There 
are no serious objections to severing them, but if this is done it is better 
to locate them and tie them off with absorbable catgut on either side 
of the median line before dividing them. The venous oozing may be 
controlled by pressure, or, if too profuse, the venous trunks may be 
ligated. 

(d) Incision of the thyroid cartilage: This should be done in the 
median line with knife or scissors (Fig. 340). The knife is preferable 
unless the cartilage has become ossified, as the dissection can be carried 
to the mucous membrane without cutting it. This is important, as the 
incision through the membrane at the anterior commissure of the glottis 
should be exactly in the median line, as otherwise one of the cords will 
be injured. 

(e) Incision through the mucous membrane: First locate the 
median line at the anterior commissure. If in doubt, begin the incision 
at the upper limit of the wound, and cut downward to the anterior 
commissure. The knife should then be inserted through the incision and 



The line of incision for the complete or partial 
removal of the larynx. 



564 DISEASES OF THE LARYNX 

between the cords, and the incision at the commissure made from within 
outward. In this way the cords will not be injured. The incision is 
then extended to the lower limit of the thyroid cartilage. 



Fig. 340 



Fig. 341 





Laryngofissure. Tracheotomy has been per- 
formed, a cross-puncture at the lower border 
of the thyroid made, and the scissors blade 
introduced through it preparatory to making 
the incision through the anterior commissure 
of the thyroid cartilages. (After Moure.) 



Laryngofissure (thyrotomy) completed, the 
tumor exposed ready for removal. (After 

Moure.) 



(/) The larynx should then be opened by retracting the two thyroid 
cartilages from the median line (Fig. 341). This is done by the assistants 
with retractors. 

(g) Removal of the growth: Having completed the laryngofissure, 
and having separated the incised thyroid cartilages, the location and 
character of the growth should be studied. The growth may be re- 
moved through the laryngofissure with a snare, scissors, or knife. The 
better surgical procedure is with the knife or scissors, as with either of 



MALIGNANT NEOPLASMS OF THE LARYNX 565 

these instruments the scope of the operation is entirely under the control 
of the operator, whereas with the snare the depth of the cut cannot be 
accurately estimated. 

(K) Hemorrhage: The hemorrhage in the preliminary part of the 
operation, i. e., the laryngofissure, is comparatively slight, as it is con- 
trolled by pressure and ligatures as the bleeding points appear. In the 
removal of the growth, however, there may be considerable hemorrhage 
both during and after the operation. This is easily controlled with 
artery forceps or with the actual cautery applied to the bleeding areas. 
The hemorrhage which occurs after the patient becomes conscious is 
expectorated, and causes little or no trouble. During the operation the 
patient's head should hang over one end of the table, which should 
be lowered to prevent aspiration of blood into the lungs. 

(z) Closure of the laryngofissure: Having removed the neoplasm (or 
foreign body), the thyroid cartilages are reunited with an absorbable 
ligature. The coaptation of the cut edges of the cartilages should be 
carefully done. If, for instance, one side is higher than the other the 
vocal cords at the anterior commissure will not approximate on the same 
level, and vocalization will be somewhat modified. 

(y) Closure of the cutaneous wound : This should be done with sim- 
ple sutures about one-fourth of an inch apart, and the whole covered 
with plain sterile gauze. The tracheotomy tube may be removed in 
twenty-four hours or at the end of the operation, and the wound entirely 
closed. At the end of from three to six days the stitches should be 
removed. At this time the wound should be thoroughly healed, little 
additional attention being required. 

Laryngofissure is also the preliminary step in the treatment of stenosis 
of the larynx, in which the tracheotomy tube with the upward extending 
rubber tube in the chink of the glottis is used. 

3. Subhyoid Pharyngotomy. — Subhyoid pharyngotomy for the removal 
of malignant neoplasms of the larynx is rarely used. There are cases, 
however, when it should be elected for this purpose in preference to 
any other method. 

Indications : The indications for subhyoid pharyngotomy are few, 
and it is used chiefly in cases of extrinsic malignant neoplasms of 
the larynx, and in cases complicated by extension to or by origin in 
the pharynx. They are as follows: 

(a) When the growth is situated in the epiglottis or other of the higher 
portions of the larynx. 

(b) When the growth is situated in the upper portion of the larynx 
and involves the pharyngeal wall. 

(c) When the malignant growth begins in the pharynx and extends to 
the supraglottic (extrinsic) portion of the larynx. 

Technique. — (a) Place the patient under chloroform or ether anesthesia 
per rectum or mouth after the usual preliminary preparations. 

(b) Prepare the neck and face by cleansing, etc. 

(c) Elevate the shoulders of the patient by placing a sand pillow under 
them, and draw the head well backward to bring the hyoid region into 



566 



DISEASES OF THE LARYNX 



easy access. Also elevate the foot of the operating table to prevent blood 
and secretions entering the trachea while the reflexes are abolished by 
tfie anesthetic. 

(d) Make a transverse incision through the skin after Kocher's method, 
beginning about \ inch below the inferior border of the hyoid bone, and 
extend it from the anterior border of the sternocleidomastoid muscle 



Fig. 342 




Hemilaryngectomy for intrinsic carcinoma of one-half of the larynx. 



to the corresponding point on the opposite of the neck. The incision 
should be from 2\ to 3 inches in length. Then make a perpendicular 
incision in the median line, beginning above the transverse incision, 
and extending downward to the prominence of the thyroid cartilage. 

(e) Divide the superficial fascia, in which the anterior jugular vein 
is found. The jugular vein should be ligated in two places on each 
side of the neck and severed between the ligatures. 



MALIGNANT NEOPLASMS OF THE LARYNX 567 

(f) Sever all the muscles, including the sternohyoid, on either side of 
the median line, and just beneath them the thyrohyoid muscles, thus 
exposing the thyrohyoid membrane to view. 

(g) With the finger applied to the membrane, explore for the epiglottis, 
so as to avoid injuring it in the next step of the operation. 

(h) Incise the thyrohyoid membrane, thus exposing the diseased area 
to inspection. 

(i) Carefully inspect the deeper field, beginning at the anterior surface 
of the epiglottis, for evidences of a malignant growth. 

(y) Seize the epiglottis with toothed forceps, and gently draw it out- 
ward through the wound, securing it with either a suture through its 
tip or with locked forceps. 

(k) Traction upon the epiglottis opens the wound and exposes the 
deeper parts to view. 

(I) Through the opening all diseased tissue is removed with scissors, 
knives, and double cutting forceps, some of the surrounding healthy 
tissue being also included. 

(m) The wound is now closed by suturing the thyrohyoid membrane, 
the muscles, and the superficial fascia with absorbable catgut, and the 
skin with non-absorbable ligatures. 

(n) The external wound should be painted with tincture of iodine, 
to prevent stitch abscesses, and a gauze dressing applied. 

(o) The dressing should be removed in three to five days and renewed. 
The stitches in the skin should be removed on about the fifth or sixth 
day. 

(p) At the end of ten or twelve days the patient should be able to leave 
the hospital. 

4. Partial Laryngectomy. — This operation is often spoken of in the 
literature as synonymous with laryngofissure, which is but the prelimi- 
nary step in partial and hemilaryngectomy. Partial laryngectomy is a 
more extensive operation than simple laryngofissure. In laryngofissure 
only the soft parts and the growth are removed, whereas in partial laryn- 
gectomy a portion of the cartilaginous framework is removed with the 
growth. 

Indications. — The indications for partial laryngectomy are somewhat 
different from those for laryngofissure. For example, it is not indicated 
for the removal of foreign bodies in the larynx, benign neoplasms, or 
of cancerous growths, which only involve the soft structures. 

The following are the chief indications : 

(a) When malignant growths are limited to the soft parts on one side 
of the larynx, and when it is suspected that the cartilage is also involved, 
a partial laryngectomy may be done. 

(b) When malignant growth is limited to one side and involves a 
portion of the cartilaginous framework of the larynx. The removal of 
the growth and the portion of the cartilage involved is regarded as 
sufficient to obliterate all traces of the growth. If partial laryngec- 
tomy will not obliterate the growth, complete laryngectomy should be 
performed. 



568 DISEASES OF THE LARYNX 

(c) If for any reason there is a suspicion of involvement of the deeper 
structures, partial laryngectomy is indicated. 

Technique. — The technique is so little different from that given in 
laryngofissure, that a detailed description is unnecessary. The chief 
difference consists in the removal of the affected portion of the carti- 
laginous framework in addition to the procedures practised in laryngo- 
fissure, in which only soft tissues are removed. The additional fact that 
partial laryngectomy is usually indicated in extrinsic cancers also implies 
a more serious condition, with earlier glandular involvement. Hence, the 
anxiety and desire to be certain to include all the diseased tissue, even 
at the expense of some healthy tissue. 

5. Complete Laryngectomy.- — The removal of the larynx is a formidable 
and sad procedure. The death rate in the hands of the average operator 
is high. The condition of the patient, should he recover from the opera- 
tion, is often pitiable indeed, though this fact does not always appear in 
the published reports. However, from the patient's point of view he 
would rather be alive without his larynx than dead with it. Complete 
laryngectomy may, therefore, be done when simple and less radical 
measures hold out little or no hope of success. 

Indicatians. — In a general way, it may be said that the total removal, 
of the larynx is indicated in those cases in which the disease involves 
a large portion of the soft and cartilaginous structures in both lateral 
halves of the larynx. It may also be indicated when one side is involved 
in its entirety and there is a strong suspicion that it has also invaded 
the opposite side. 

The following fairly represents the chief indications for complete 
laryngectomy : 

(a) The involvement of one-half of the larynx, with a strong suspicion 
that it has invaded the opposite side, the glands of the neck not being 
involved. 

(5) The involvement of both sides of the larynx, especially if the carti- 
laginous framework is included in the process, the glands of the neck not 
being involved. 

(c) The involvement of the extrinsic areas of the larynx on both sides. 
If the intrinsic portions only, as the vocal cords, are invaded by the 
cancerous growth, it may be successfully operated on by laryngo- 
fissure. 

_ (d) The involvement of the extrinsic portions of the larynx on both 
sides, together with the contiguous tissues, as the pharynx, necessitates 
the total extirpation of the larynx, together with the other structures that 
are cancerous. 

(e) When both sides are extrinsically more or less involved, together 
with the glands of the neck, total laryngectomy and the ablation of all 
the lymphatic glands on both sides of the neck are indicated, though a 
fatal result will probably follow. 

Technique. —The method of W. W. Keen is probably the simplest, 
safest, and most thorough which has yet been devised, and is the one 
used by me. It is given in the following description : 



MALIGNANT NEOPLASMS OF THE LARYNX 



569 



(a) The preparation of the patient for the operation bears an impor- 
tant relation to the success or failure of the surgical procedure. If the 
patient's general health is bad the prognosis is correspondingly bad. 
It is essential, therefore, that the general condition of the patient be 
improved by a short course of forced feeding and tonic remedies. The 
operation should be performed in the morning, when the vital forces 
are at their best. On the evening prior to the operation, a cathartic 
should be given, and a saline given early the following morning. The 
face (adult male) and neck should be shaved and cleansed the day before 
the operation, and a moist carbolic acid dressing applied. 

Fig. 343 




The superficial soft tissues dissected from the larynx preparatory to the complete removal of 
the carcinomatous larynx. The remaining soft tissues should be dissected from the larynx before 
separating the posterior wall of the larynx from the esophagus. 

(6) On the following morning the patient should be placed upon the 
operating table in the Trendelenburg position, with the foot of the table 
raised to prevent the aspiration of blood into the trachea. The patient 
should have his head lowered throughout the operation, and for three 
days after it. 

(c) Ether vapor, per rectum, as recommended by Cunningham and 
Stucky, is, perhaps, the best method of inducing anesthesia, as the anes- 
thetist and his apparatus (Cunningham's) are removed from the field 
of operation. 



570 



DISEASES OF THE LARYNX 



The anesthetic may be administered by the mouth or the tracheotomy 
tube (in case a preliminary tracheotomy has been performed), or, if 
tracheotomy is performed during the operation, it may be given by the 
mouth until tracheotomy is performed, and then through the tracheotomy 
tube. 

If tracheotomy is not done either before or during the operation, the 
anesthetic may be given by mouth until the trachea is severed from the 
cricoid cartilage, and then through the stump of the trachea. 

(d) The incision should be made in the median line, beginning at the 
hyoid and extending downward to the sternal notch (Fig. 339). The 
only vessels of any consequence encountered are the superior and infe- 



Fig. 344 



Fig. 345 





Carcinoma of the larynx removed by com- 
plete laryngectomy. Posterior view (Au- 
thor's case.) 



Carcinoma involving all of one and part 
of the other half of the larynx. Complete 
laryngectomy was performed by the author 
by Keen's method without tracheotomy. 
Anterior view. (Author's case.) 



rior laryngeal arteries and their branches. The arteries and veins should 
be ligated as they are exposed (Plate XIV). The venous hemorrhage 
may be controlled by pressure, or the larger trunks may be tied. 

(e) Separate the soft structures (Fig. 343), including the muscles in 
the median line, and dissect them from the larynx down to the esophagus 
on the posterior wall of the larynx. 

(/) Introduce a heavy anchor suture between the first and second 
cartilaginous rings of the trachea on either side, and pass one end of the 
suture through the adjacent skin, as shown in Fig. 346. This is done 
to prevent the trachea dropping into the mediastinum when it is severed 
from the larynx. 

(g) Tie the anchor sutures described in the preceding paragraph, and 
sever the trachea from the cricoid ring of the larynx with a sharp scalpel. 



PLATE XIV 




Arteries of the Larynx. 



The superior laryngeal and the inferior laryngeal arteries, branches of the superior 
and inferior thyroid arteries, respectively, supply the walls, glands, muscles, and 
mucous membrane of the larynx. 



MALIGNANT NEOPLASMS OF THE LARYNX 



571 



If the anesthetic has been given by the mouth, it should be transferred to 
the trachea. 1 

(Ji) Dissect the posterior wall of the larynx from the esophagus with 
the finger or blunt instrument, as shown in Fig. 346. This is often a 
difficult task, as the adhesions are firm. Every effort should be made to 
avoid tearing the wall of the esophagus, as it is difficult to repair it by 
suture. 

Fig. 346 




Complete laryngectomy. The larynx has been severed from the trachea at the junction of the 
first ring and the cricoid cartilage. The larynx is being separated from the anterior wall of the 
esophagus by blunt dissection. 

(i) Having separated the esophagus from the larynx as high as the 
arytenoid cartilages, it should be severed from the larynx by transverse 
incision (Fig. 348). 



1 In this description, it is presumed that the removal of the larynx is done without tracheotomy 
either prior to or during the operation, as suggested by Dr. W. W. Keen. I performed the opera- 
tion in this manner in August, 1905, with satisfaction. The larynx and carcinoma thus removed 
are shown in Figs. 344 and 345. The patient died six days after the operation from exhaustion. He 
rallied after the operation, progressed very favorably for five days, took food per rectum for four 
days, and by mouth for one. He was then unable to retain food on his stomach. Rectal feeding 
was again tried, but was not retained. Death occurred the following day. The patient was fifty 
years old, and had been a heavy whisky drinker for twenty-five years. The carcinoma was extrinsic 
and large, and while chiefly limited to the right half of the larynx, it had extended to the left side 
of the epiglottis. There was no enlargement of the glands of the neck. Only one enlarged lymphatic 
gland was found, and that was in the glosso-epiglottic space. 



572 



DISEASES OF THE LARYNX 



(j) The only attachment remaining is the thyrohyoid membrane in 
front. This should also be severed by a transverse incision (Fig. 348). 
The larynx and the neoplasm are thus extirpated, leaving the pharynx 
open in front. 

(k) The lower pharyngeal membrane should now be sutured to the 
thyrohyoid membrane below the hyoid, as shown in Fig. 348, thus 
closing the wound in the anterior wall of the pharynx. 



Fig. 347 




Complete laryngectomy. The thyroid glands turned aside with ligatures through them. The 
trachea severed below the cricoid cartilage preparatory to dissecting the larynx from the esophagus 
and other deep soft tissues. Anchor sutures passed through the upper ring of the trachea to pre- 
vent the trachea dropping into the mediastinum, a, thyrohyoid membrane. 



(I) The soft tissues should be brought together in the median line 
by buried absorbable catgut sutures. 

(m) The stump of the trachea should be securely sutured to the skin, 
as the breathing must in future be carried on through it. 

(n) The skin should be closed by sutures except around the stump 
of the trachea, as shown in Fig. 349. 

(o) A dressing should be applied over the line of skin sutures. A 
few folds of thin moist gauze should be placed over the tracheal stump 
to filter and moisten the air inspired through it. This portion of the 



MALIGXAXT NEOPLASMS OF THE LARYNX 



573 



dressing should be frequently changed, as it becomes soiled by the 
secretions coughed out through the trachea. 

After-treatment. — Keep the foot of the bed elevated a foot or more 
for three days, to promote drainage of the trachea, or until the patient 
can take food by the mouth. Sustain the patient by rectal feeding at 
intervals of three or four hours for four days. At the end of this time 
the pharyngeal wound is usually united, and food may be given by 
mouth. In from twelve to fourteen days, the patient should be able to 
leave the hospital, if he is not dead. 



Fig. 348 




"omplete laryngectomy. The larynx has been removed, leaving an opening in the anterior wall 
of the pharynx. The sutures are in position ready to close the wound. 



Ill 



laryngeal 



Axioms. — 1. Early diagnosis and an early operation 
cancer means a probable cure. 

2. An early provisional diagnosis of cancer may be made if three 
clinical facts are borne in mind, namely, a patient forty or more years old, 
complaining of continued hoarseness without cough, with sudden sharp 
pains in the larynx, pharynx, or ears. 

3. The operation of choice should be the one that will insure the com- 
plete removal of malignant tumor with the least destruction of normal 
healthy tissue and the least damage to the function of the larynx. 



574 



DISEASES OF THE LARYNX 



4. Intrinsic cancer of the larynx is successfully treated by laryngo- 
fissure, a simple and comparatively safe method. 

5. Complete removal of the larynx is a formidable and dangerous 
operation, only suited to extensive involvement of the soft and the carti- 
laginous portions of the larynx in both lateral halves. 

6. Extensive involvement of the larynx and of the adjacent structures 
means certain death without an operation, and probable death with an 
operation. 

7. If the diagnosis of cancer of the larynx is only made at an advanced 
stage, the physician is guilty of " ignorance," when it is easy to be ''wise." 



Fig. 349 






The incision after complete laryngectomy. The end of the trachea is sutured to the skin. 



Postoperative Considerations. — The surgeon's responsibilities are by 
no means ended when the operation is completed. There are several 
conditions which are either present or likely to arise that demand his 
thoughtful attention. Among them are the following. 

1. Shock and Sudden Death. — Stoerk attributes death by shock to the 
severing of the fibers of the inhibitory cardiac branches of the pneumo- 
gastric nerve. They are given off, and pass forward to the larynx, thence 
downward back of the trachea, where they may be injured in separating 
the esophagus from the larynx and the trachea. It is, therefore, well 



MALIGNANT NEOPLASMS OF THE LARYNX 575 

to keep close to the posterior wall of the trachea, and to avoid undue 
manipulation and traumatism in making the separation. 

Crile, bv experimentation upon the lower animals, arrives at the con- 
clusion that sudden death in laryngectomy and intubation is due to an 
irritation of the middle and the upper portion of the larynx, the irritation 
exciting a reflex inhibition of the cardiac branches of the pneumogastric 
nerve. He therefore recommends a preliminary incision through the 
cricoid membrane, through which the interior of the larynx may be 
brushed with a 5 per cent, solution of cocaine. After that is done, the 
operation of election is continued. He also suggests that an injection 
of atropine helps to prevent the reflex influence upon the heart. He 
makes the following distinction between asphyxia and reflex action on 
the respiratory organs and the heart: 

(a) In asphyxia there are more or less violent efforts to breathe, the 
heart momentarily beating stronger; whereas, 

(b) In reflex disturbances the breathing stops suddenly and the heart 
immediately becomes weak. 

The above distinctions are peculiarly applicable to impending death 
during intubation in diphtheria and pseudomembranous croup. During 
intubation, the patient is suddenly asphyxiated, or is thrown into a state 
of shock, the characteristics of each being given in the above paragraph. 

Treatment of Cardiac Reflexes. — (a) Instantly lower the head without 
further manipulation of the larynx. 

(b) Slap the chest with a cold, wet towel, then immediately dry the 
surface and repeat the cold applications. 

(c) Artificial respiration should, in the meantime, be kept up. 
Treatment of Asphyxia. — (a) Remove the intubation tube or the 

obstruction to the larynx and clear it of membrane. 

(b) The patient will then, in all probability, cough out more membrane 
or obstructing secretions, thus clearing the lumen of the trachea. 

(c) Reintroduce the cannula (in diphtheria), and no further trouble 
will be likely to occur. 

While the foregoing remarks upon shock and sudden death do not, in 
all respects, have a direct bearing upon the operation for cancer of the 
larynx, they nevertheless have an indirect relationship, and may prove of 
value in the study of this subject. 

2. Inspiration pneumonia is a common sequel of the operative treat- 
ment of laryngeal cancer, and is a frequent cause of death. In laryngo- 
fissure, one of the simplest external laryngeal operations, the death rate 
is about 4 per cent. In complete laryngectomy the mortality from 
pneumonia alone is much greater. 

3. Rectal Alimentation. — After complete laryngectomy the patient 
should be sustained by rectal alimentation for three or four days, after 
which he may be given food by the mouth. In the simple operations, the 
rectal feeding may be discontinued somewhat earlier, proportionate to 
the extent of the operation. Indeed, in simple laryngofissure it may be 
dispensed with altogether. 

4. The Voice. — After laryngeal operations, the voice may be good, 
if the cords are not greatly damaged in the removal of the growth or 



576 DISEASES OF THE LARYNX 

the larynx is not removed in its entirety. If the tumor arises from the 
cords, and has penetrated deeply into their substance, they must be 
removed, and the voice is consequently weak and otherwise impaired. 
After laryngofissure for laryngeal cancer, the voice is usually more or 
less impaired, while in benign growths it is usually very good. After 
hemilaryngectomy and partial laryngectomy, one cord remains, and 
gives a husky though useful voice. After complete laryngectomy, when 
the trachea is stitched to the skin, there is no voice except in rare cases, 
where the tissues around the tracheal opening are thrown into vibration. 
When the trachea is stitched to the pharyngeal wound there may be 
more or less voice. This is obtained by the peculiar conformation of the 
parts after the healing process is complete. The larynx being removed, 
the base of the tongue drops backward and downward, approximating 
the posterior wall of the pharynx. The cavity below the base of the 
tongue forms an air chamber, which is utilized to force air through 
the constriction formed by the base of the tongue and the pharyngeal 
walls, thus throwing the tissues at this point into vibration. The union 
of the trachea to the pharyngeal wound is not often practised, as the 
tension is So great that the tissues tear apart, slough away, or undergo 
gangrenous degeneration. 

5. Recurrence. — Recurrence of the cancerous growth is common on 
account of failure to make an early diagnosis. Intrinsic growths are 
less malignant than the extrinsic, hence recurrence in this variety is not 
so common. 

It may be said, then, that recurrence of laryngeal cancer is largely 
dependent upon the following factors: 

(a) Intrinsic cancers of the larynx do not recur as frequently as the 
extrinsic. 

(b) Conversely, extrinsic cancers more often recur than the intrinsic. 

(c) Extralaryngeal cancers, involving the larynx, have a still greater 
tendency to recurrence. 

(d) An early diagnosis and operation by laryngofissure, in intrinsic 
cancer of the larynx, should result in a death rate of only 10 per cent., 
and 5 of the 10 die of pneumonia rather than of recurrence. 

(e) Complete laryngectomy in cancer of the larynx was, up to 1889, 
attended with a death rate of 44 per cent., but since antiseptic surgery 
and an improved technique have been attained, it is reduced to about 
15 per cent. When I speak of a death rate of 15 per cent., I mean death 
within three years after the operation. Quite a number die within a 
few months from pneumonia, septicemia, gangrene, exhaustion, or other 
sequelae. In still others recurrence brings on a fatal issue. 

(J) The ligation or injection of the external carotids and their branches 
should only be done when the cancer is inoperable, as it does not cure, 
but only holds out the hope of retarding the growth of the tumor by 
diminishing its nourishment. 

(g) Tracheotomy should be reserved for inoperable cases in which 
the cancerous tumor obstructs the breathing and threatens the life by 
suffocation. 



CHAPTEE XXXI 

FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND 

ESOPHAGUS^ 

Etiology. — The lodgement of foreign bodies in the air passages is 
most common in infants and young children, as they have an instinctive 
desire to test all substances with their mouths. Coughing, laughing, 
crying, and ineffectual attempts to swallow draw the foreign bodies into 
the lower air tract. The small caliber of the larynx and air tubes in 
infants and young children increases the chance of lodgement of foreign 
bodies. The smaller size of the larynx and air tubes in infants and 
young children renders the obstruction greater than in older subjects 
from the same foreign bodies, hence the danger is correspondingly 
greater in young subjects. 

The nature of the foreign bodies ranges anywhere from particles of 
food to marbles, coins, safety pins, burrs, and false teeth. 

Symptoms. — The symptoms of a foreign body in the respiratory 
passages are those of obstructed breathing, laryngeal, tracheal, bronchial 
or pulmonary irritation, and inflammation. The patient is suddenly 
seized with a violent choking and suffocative attack, characterized by 
cyanosis, aphonia, beads of perspiration on the forehead, and a weak 
pulse. These symptoms usually subside within a few minutes, but return 
again in a few hours or days. After the foreign body remains in the 
larynx for several weeks the spasmodic symptoms cease and the cough, 
etc., become more constant, often leading to a diagnosis of tuberculosis. 
A negative finding upon examination of the sputum removes the suspicion 
of tuberculosis. A positive finding does not, however, exclude a foreign 
body. A history of spasmodic cough and dyspnea and hoarseness fol- 
lowed by a persistent cough should excite suspicion of a foreign body 
in the respiratory tract if the patient is a small child. If the foreign 
body lodges in the ventricle of the larynx or in the subglottic space, 
hoarseness or aphonia is usually present. When the foreign substance 
changes its position, or a fresh irritation arises, new suffocative attacks 
are excited. If the foreign body lodges in the trachea, bronchus, or 
one of the bronchioles, the voice remains clear. Bronchial rales or 
pneumonia may subsequently develop. In some instances the move- 
ments of the foreign body when in the bronchus may be detected by 
auscultation (Halstead). Blood-stained expectoration is occasionally a 
symptom. In some instances all symptoms and physical signs are 

1 Revised by Dr. Chevalier Jackson, whose distinguished work in this field is unique and 
unequalled. 

37 ( 577 ) 



578 DISEASES OF THE LARYNX 

strangely absent even when the bodies of considerable size are present. 
Dyspnea, attended with an elevation of temperature, often leads to an 
erroneous diagnosis of tracheal diphtheria. A laryngoscopic examina- 
tion may not reveal the foreign body, even though it is lodged in the 
ventricle of the larynx. By direct laryngoscopy (Fig. 351), a better 
view of the larynx may be obtained. To Gustav Killian belongs the 
credit of devising instruments whereby almost all of the respiratory 
tract may be clearly inspected for foreign bodies. This alone is enough 
to immortalize him in the scientific annals of medicine and surgery, 
though he has in many other ways made his name equally famed in 
rhinology and laryngology. 

Indications. — The indications are to remove the foreign body as 
soon as possible, as it may become dislodged and migrate to a new and 
more dangerous location. The continued presence of the foreign body 
may also give rise to considerable local irritation and subsequent edema 
or septic inflammation. Pneumonia is a rather frequent complication. 
In prolonged cases serious septic absorption may occur. Cases are re- 
corded wherein the foreign body remained in the air passages for years 
without causing death. It should not be deduced from this fact that 
the early removal of the foreign body is not desirable, as the risks attend- 
ing its continued presence in the air passages are infinitely greater than 
those incident to its early removal. 

The indications are, therefore, to institute proceedings for its removal, 
either by (a) holding the child's head downward and thumping it on the 
back (a dangerous procedure), the surgeon being prepared to perform 
a tracheotomy should suffocative symptoms supervene; (6) the titra- 
tion of the larynx with the finger, in the hope of dislodging the foreign 
body or of exciting a coughing spasm, during which it may be expelled 
(a dangerous procedure); (c) the indirect removal with instruments 
by the aid of a laryngoscopic mirror; (d) the removal of the foreign 
body by the direct method with the Killian or the Jackson tubes; (e) 
tracheotomy to relieve the suffocative dyspnea; if cyanosis is marked, 
tracheotomy may also be done to establish a new avenue of inspection 
and for the instrumental removal of the foreign body; (/) and, finally, the 
indications are to have a skiagraph made to accurately locate the foreign 
body. If it is a metallic or bony substance, its location is easily shown; 
whereas if of vegetable matter, it is less easily shown on the skiagraphic 
plate, and in any case we must not be misled by negative radiographic 
findings. Many cases of failure to show even metallic bodies on other- 
wise excellent skiagraphs have been reported. 

Having located the foreign body, practise bronchoscopy or tracheos- 
copy, and remove it with suitable instruments, by either upper or lower 
bronchoscopy, upper bronchoscopy being preferable when practicable. 

Treatment. — It is generally understood among the laity that pound- 
ing a child on the back, especially when held head downward, will often 
dislodge a foreign body from the respiratory tract. These procedures 
have, therefore, usually been performed before a physician is called, 
provided it is known that a foreign body has been inhaled. Even though 



PLATE XV 




Lower Bronchoscopy. 



a, the electric wire supplying the lamp at the distal end of the bronchoscopic tube; 

b, the conduit for aspirating the secretions and blood from the distal end of the tube; 

c, the tracheotomy wound ; d, the distal end of the tube ; e, the larynx ; /, the foreign 
body; //, the lungs. 



FOREIGN BODIES IN THE LARYNX 579 

the foreign body is not thus removed, the suffocative symptoms often 
subside within a few. minutes, and the incident is often forgotten. This 
method of procedure is dangerous, as the foreign body may be inspired 
deeper into the air passages instead of being expelled. If the physician 
is present, he should prepare to do a tracheotomy if the suffocative 
symptoms demand it. If the child is in a fairly comfortable condition, 
it should be removed to a hospital and all arrangements for any emer- 
gency be made, before an attempt is made to remove the foreign body. 
When the symptoms recur a few hours or days later, without the marked 
strangulation and coughing which characterized the initial attack, the 
family often sees no connection between the two, and fails to report the 
occurrence of the first one to the attending physician. If the foreign 
body assumes a new location, the violent spasmodic seizures are repeated. 

If suffocation is imminent, tracheotomy should be performed at once, 
for, as Chevalier Jackson says, if this is not done, the child may never 
breathe again. When this is done, it may be necessary to employ artificial 
respiration even if the foreign body is in the larynx. If it is in the trachea 
or bronchus, it may not relieve the distress unless the foreign body is 
expelled through the tracheal wound. As a matter of fact, it is frequently 
thus expelled the moment the edges of the severed tracheal rings are 
retracted. If it is not voluntarily expelled, the lining mucous membrane 
of the trachea should be titillated, a procedure that sometimes causes its 
expulsion. Having performed tracheotomy, which is not attended with 
voluntary expulsion of the foreign body, proceed to pass a probe upward 
through the tracheal wound into the larynx, to locate it if it- is there. If 
lodged in the ventricular pouch or in the subglottic space, its removal is 
not difficult. Having located it, introduce slender forceps, seize it, and 
remove it through the tracheal wound. 

If the foreign body is lodged in the trachea at its bifurcation, it may be 
easily seen through a tracheoscopic tube introduced through the trache- 
otomy wound (Plate XV). For illumination, a Kierstein head lamp 
(Fig. 350) or a small electric lamp at the distal end of the tube, as devised 
by Jackson (Fig. 351), may be used. If a Killian or Jackson tube is 
not available, the foreign body may be detected with a probe intro- 
duced through the wound, after which slender forceps may be introduced 
through the wound without a tracheoscope and the foreign body removed. 
This method is inexact and crude, and should only be used as an emer- 
gency measure. 

If the foreign body is in one of the bronchi, its removal is more difficult. 
Indeed, if it is not voluntarily expelled upon making the tracheal open- 
ing, or upon titillating the tracheal mucosa, a bronchoscope should be 
introduced through the mouth or the tracheotomy wound. 

I am greatly indebted to Dr. Chevalier Jackson for personal instruc- 
tion and for the description of the technique of tracheobronchoscopy 
given in his classical treatise upon this subject. In describing the tech- 
nique of the various procedures for the removal of foreign bodies from 
the upper respiratory tract, I have adhered to his methods and largely 
to the instruments devised by him. In so doing, I am not unmindful 



580 



DISEASES OF THE LARYNX 



of the fact that the greatest credit is due to Prof. Gustav Killian, ol 
Freiburg, who was the first to remove a foreign body from a bronchus 
by upper bronchoscopy, and who has, through his writings and demon- 
strations, made bronchoscopy available to every specialist throughout 



Fig. 350 




Kierstein's lamp. 



Fig. 351 




Jackson's slide speculum for direct laryngoscopy. The handle B gives great leverage and greatly 
aids in overcoming the resistance of the muscles at the base of the tongue when the epiglottis 
and tongue are lifted forward. 

the world. Jackson's illuminated bronchoscopic tubes are, however, 
easier for the inexperienced surgeon to use, and for this reason I recom- 
mend them in this work, though the latest apparatus, devised by Kil- 
lian's assistant, are most ingenous and admirable, and in many instances 
are better adapted for the work than Jackson's tubes. 



FOREIGN BODIES IN THE LARYNX 581 

Much credit is also due to Dr. Ingals, one of the first Americans 
to adopt bronchoscopy, for his writings, wherein he reports thirteen 
foreign bodies searched for or removed by bronchoscopy. Two deaths 
have followed the removal of foreign bodies in his practice, the cause 
of death being attributed to reflex irritation of the vagus nerve. 

Tracheoscopy and Bronchoscopy. — Preparation of the Patient. — If a 
general anesthetic, preferably ether, is used, the patient should be pre- 
pared as for a surgical operation. The morning hour, before the patient 
has had breakfast, is, therefore, the most favorable time, though in 
many cases the imminent danger in which the patient is placed leaves 
no choice in this respect. If time permits, the bowels should be emptied. 
If the tracheobronchoscope is to be used through a tracheal wound, the 
neck should be shaved and cleansed. This route, as suggested by Jack- 
son, is aseptic immediately after the tracheotomy, as the instruments may 
be introduced through a sterile wound; whereas if they are passed a day 
or two later, after the inevitable tracheotomy wound infection, the dan- 
ger of septic infection of the deeper air passages is more likely to occur. 
Upper bronchoscopy should be practised when feasible, and with the 
skill that comes with practice, tracheotomy will never be necessary except 
for dyspnea. Any foreign body that has gone down through the glottis 
can and should be safely brought out by the same route. 

The Anesthetic. — Stolid adults tolerate the introduction of the tubes 
under cocaine anesthesia, whereas more excitable ones, and children, 
require a general anesthetic. The larynx and trachea may be cocainized 
by cotton- wound applicators before the introduction of the tubes, whereas 
bronchi and secondary and tertiary bronchioles can only be reached 
after the tube is introduced (Jackson). Ether is the safest anesthetic. 
Ethyl chloride should not be used, as it is not well tolerated by the lower 
respiratory tract. Profound anesthesia may be induced, though it is 
an advantage to retain enough of the reflexes for the patient to aid in 
disposing of the secretions, thus preventing the occurrence of aspiration 
pneumonia. Morphine, codeine, and heroin, hypodermically, lessen the 
amount of general anesthetic needed, though they increase the risk of 
pneumonia by paralyzing the cough reflex (Jackson). 

Position of the Patient. — Killian usually passes the tubes with the 
patient in the lateral recumbent position under chloroform anesthesia. 
Jackson prefers ether anesthesia, with the patient in the recumbent pos- 
ture (Fig. 352), as it is less tiresome for the operator to sit than to stand 
during what is often a prolonged ordeal. The head of the patient is also 
steadied more readily in this position. Jackson prefers the recumbent 
posture, also because the patient is in position for tracheotomy should 
suffocation occur during the attempted upper bronchoscopy. The head 
should be supported over the end of the table, in Boyce's position, and 
should be firmly grasped by an assistant, as shown in Fig. 352. The 
head should not be turned to one side, but should be held exactly in the 
middle line during introduction of the tubes. If the tube is to be intro- 
duced through the tracheal wound, the head should be turned to one 
side to remove the chin from the axis of the tube. 



582 



DISEASES OF THE LARYNX 



Introduction of the Tube. — A tube should be selected of the proper 
length and size to reach the required depth and to correspond with the 
caliber of the respiratory tract to be explored. The length of the tube 
will depend somewhat upon whether it is to be introduced through 
the mouth or through the tracheal wound. The shorter the tube, the 
clearer will be the field of inspection, though with Jackson's illu- 
minated tubes the length makes no difference; in fact, it is impossible 
to tell by looking through the tube whether it is 10 centimeters or 80 
centimeters in length. The size of the tube will depend upon the age of 



Fig. 352 




The position of the patient and assistant in upper tracheobronchoscopy devised by 
Dr. John W. Boyce. (After Jackson.) 



the patient and whether the trachea, bronchus, or one of the bronchioles 
is to be explored. The secondary and tertiary bronchi may only be 
explored with small tubes. Having selected a tube of the proper size 
and length, an assistant should regulate the light and hand it to the oper- 
ator. The tube should then be passed to the desired depth. This 
assistant should have entire charge of the tubes and dry-cell battery (Fig. 
353), which furnishes the energy for the electric light at the distal end of 
the tube. The bayonet catch is used by the operator himself to turn the 
light on and off, as needed. A second assistant stands at the instrument 



FOREIGN BODIES IN THE LARYNX 



583 



table to pass to the operator, forceps, hooks, and sponge holders armed 
with little folded gauze sponges, with which the field is kept clear of 
secretions. The third assistant should hold the patient's head in position. 



Fig. 353 




Battery for illuminating Jackson's tubes. 
Fig. 354 




Jackson's exhaust pump for removing secretions in esophagoscopy and rarely in tracheo- 
bronchoscopy. 

The anesthetist should closely observe the pulse and respiration, as they 
may stop through reflex irritation excited by the presence of the broncho- 
scope in the trachea. 



584 DISEASES OF THE LARYNX 

Inspection. — The tumor or foreign body should be sought for at 
the depth of the tube by direct inspection through it. The illumination 
is brilliant, and a clear view may be obtained in most subjects if the 
secretions are removed by cotton-wound applicators, or sponge holders. 

The Removal of a Foreign Body or Growth. — Long shanked hooks and 
forceps (Fig. 355) are introduced through the tube, the growth or foreign 
body seized and withdrawn. It often requires patience and perseverance 
to accomplish the purpose in hand. If the tube has been either carelessly 
or roughly introduced, the mucosa may be injured, and the blood will be 
a worse obstacle to the view than the secretions. It is sometimes neces- 
sary to spend an hour or more in exploring the deeper air tract for a 
foreign body. Even then it may not be located. 

Fig. 355 




Long forceps for the removal of foreign bodies in bronchoscopy. 

Having completed the exploration successfully, the tracheotomy wound, 
if one has been made, may be allowed to close at once, even though the 
obstruction to breathing is not completely relieved. The embarrassment 
which still remains is usually due to the congestion of the respiratory 
tract in the region formerly occupied by the foreign body, and will dis- 
appear in from three to seven days. If the foreign body is not found, 
or, if found, is not removed, the tracheotomy tube may be left in place 
indefinitely, or until such time as the foreign body is found or is expelled 
voluntarily. 

Complications and Sequelae.— When tracheoscopy and bronchoscopy 
are performed through the mouth under a general anesthetic, pneumonia 
is occasionally a serious sequela. If performed through the mouth under 
partial general anesthesia, or under cocaine anesthesia, such a sequela 
does not so often occur. When performed through a tracheotomy wound 
under strict aseptic precautions, pneumonia rarely follows except as 
a result of a septic condition established by the presence of the foreign 



FOREIGN BODIES IN THE LARYNX 585 

body. That is, bronchoscopy per se, when performed under good surgical 
conditions, does not often cause pneumonia. 

General Considerations. — According to Killian, foreign bodies in 
the larynx, trachea, and bronchi may be divided into (1) hard and (2) 
soft varieties. He still further subdivides them for clinical purposes 
into (a) slender, (b) flat, (c) round, (d) cubical, (e) irregular, (/) metallic, 
(g) non-metallic, (h) friable, and (i) those likely to swell. These sub- 
divisions are of clinical significance, because the size, shape, consistency, 
and chemical composition have much to do with the location and the 
technique of removing the foreign bodies. 

(a) Slender objects, as needles, pins, nails, splinters, etc., usually 
lodge with the point turned upward, and they lie diagonally across the 
lumen of the tube. Needles and pins usually cause little inflammation; 
hence, mucus and large granulations are not present to obstruct the view. 
Slender foreign bodies should be grasped with forceps (Fig. 355) near 
the point buried in the tube wall, pushed downward to disengage the 
buried point, and then removed through the bronchoscopic tube. Small 
nails may be removed with a rod-magnet introduced through the broncho- 
scopic tube. 

(6) Flat objects, as coins, buttons, pebbles (flat), usually lodge in the 
trachea, though small buttons may enter the bronchi. Coins are usually 
found in adults, as they are too large to enter the lower air tubes in infants 
and children. Children from three to six years old have a fascination 
for small flat pebbles. These usually lodge in the trachea near the bifur- 
cation. Flat objects usually stand diagonally across the lumen of the 
trachea or bronchus, and are easily grasped with forceps. They may be 
removed by upper bronchoscopy in nearly all cases. 

(c) Round objects, as glass beads, cherry stones, coffee beans, etc., are 
frequently coughed up before assistance is called. They remain movable 
for quite a while, changing position from time to time. As Killian says, 
they are difficult to grasp with the forceps on account of their shape and 
the ease with which they elude the forceps, as it pushes the foreign body 
before it. A bead or other round object is, therefore, more easily re- 
moved if it is first pushed down to the bifurcation of the trachea, where 
it may be grasped with the forceps. Oval seeds, as prune stones, are 
rough, and are easily grasped with the forceps. When present in chil- 
dren, prune stones are usually near the bifurcation of the trachea, as 
they are too large to enter the bronchi. 

(d) Cubical foreign bodies are difficult to grasp with forceps on account 
of their width. Killian recommends the use of his hook or hook forceps 
for this purpose. He also recommends lower bronchoscopy (through a 
tracheotomy wound) after failure by upper bronchoscopy. 

(e) Irregular objects, as bone fragments, are usually found in adults. 
When present in children they lodge in the trachea. If small, the frag- 
ments may enter the right bronchus. As the bone fragment is usually 
rendered sterile by cooking, infection attending its presence is some- 
what delayed. If allowed to remain in the bronchus or trachea too long, 
bronchitis, bronchiectasis, pulmonary abscess, or gangrene may develop. 



586 DISEASES OF THE LARYNX 

The bone fragments are irregularly flat, and vary in size from 14 to 16 
mm. long by 8 to 9 mm. wide. 

Carious teeth are occasionally aspirated into the trachea or bronchi, 
and when present quickly excite infective reaction. They should, there- 
fore, be removed as quickly as possible. 

Collar buttons are difficult to remove, especially when the larger flat 
end is turned upward. When the button lies crosswise of the air tube 
it may be grasped by its neck with forceps or a hook and removed. 

False teeth are usually too large to pass below the vocal cords, though 
Wild reports a case in which a plate with two false teeth entered the 
left bronchus. It was removed eleven days after the accident by lower 
bronchoscopy, after being observed by upper bronchoscopy. 

(/) Metallic substances may be clearly demonstrated by skiagraphy, 
whereas (g) non-metallic substances are less clearly defined. The 
skiagraph may, therefore, be used to locate the foreign body in many 
subjects. 

Fig. 356 



^rrrffffiTlTlTfrfrpfPrf — 




V 

Jackson's extractor. 

(h) Friable substances, as a fragment of an apple or a swollen and 
partially disintegrated bean, are difficult to remove, as they break into 
smaller fragments when seized with forceps. When thus broken the 
smaller particles are often coughed up, though it is sometimes dangerous 
to depend upon this mode of ejection, as the particles may be aspirated 
into one of the secondary or tertiary divisions of the "bronchus." Should 
this accident occur, one lobe of the lung may be deprived of air and 
rapidly undergo retrograde changes, and become the seat of infection and 
inflammation. Furthermore, the foreign body is less accessible and 
more difficult to remove when in one of the smaller bronchi. Killian 
has constructed forceps, modelled somewhat after an obstetric forceps, 
with which friable substances, as a swollen bean, fragments of apple, etc., 
may be grasped and removed without leaving fragments in the air tube. 
Jackson has devised a bean extractor (Fig. 356), for all soft bodies, such 
as beans, peanuts, pieces of potato, etc. 



FOREIGN BODIES IN THE LARYNX 587 

Barbed cereal spikes of wheat, rye, etc., are often difficult to remove, 
as the barbs usually point upward and engage in the mucous membrane 
when attempts are made to remove them. They have a tendency to 
descend gradually to the deeper tubes. A forceps that will grasp the 
entire length of the spike should be used, to prevent fragmentation. 

(/) A swollen bean, or other substance likely to swell from the ab- 
sorption of the moisture of the lower respiratory tract, may gradually 
close the lumen of the bronchial tube (secondary) and thus shut off the 
air supply to a portion of the lung. The secretions are retained and 
undergo decomposition, and finally cause serious inflammatory reaction, 
as violent fever, pneumonia, and atelectasis. According to Killian, 39 
per cent, of these cases have died. 

Killian has collected 164 reported cases of foreign bodies in the lower 
respiratory tract, which were treated by bronchoscopy. Of these, 8 
coughed the foreign body up. The result is unknown in 5, leaving 159 
cases in which the results are known. 

Twenty-one (13 per cent.) died, 2 from cocaine poisoning, 2 from 
stenosis, 16 from pulmonary complications, 5 with the foreign body in 
situ, and 11 in spite of removal. 

Upper bronchoscopy was fully successful in 54 cases. 

Lower bronchoscopy was fully successful in 63 cases. 

Of the first 18 cases occurring in Prof. Killian's practice, one died six 
months after the removal of the foreign body from severe pulmonary 
complications. 

In two he failed to find the foreign body. 

Upper bronchoscopy was performed in 12 cases. 

Upper and lower bronchoscopy in 5 cases. 

Lower bronchoscopy in 1 case. 

Dr. Jackson has extracted 61 foreign bodies from the trachea and 
bronchi all by upper bronchoscopy. He failed to find the foreign body 
in the bronchi in three cases where it showed plainly in the radiograph. 

Direct Laryngoscopy. — Direct laryngoscopy should be done as a routine 
procedure in the examination of the larynx, as by it a better view of the 
parts is obtained, and it is the only means by which the larynx of little 
children can be examined. It has rendered possible the positive diag- 
nosis or exclusion of laryngeal diphtheria in infants, and the laryngologist 
who does not use it in these cases does not do his duty. It may be done 
in the office under cocaine anesthesia, though it is a very disagreeable 
procedure. Foreign bodies and neoplasms may also be removed by 
direct laryngoscopy; indeed, this should be the method of choice, espe- 
cially in papilloma of the larynx, as repeated operations are often neces- 
sary to eradicate the disease. 

Anesthesia. — Cocaine anesthesia is usually sufficient for office examina- 
tions and for the removal of growths and foreign bodies from the supra- 
glottic portion of the larynx. First brush the larynx with a 4 per cent, 
solution of cocaine to lessen the reflex irritability, and after waiting a 
minute, swab the larynx with a 20 per cent, solution of cocaine, under 
the guidance of a laryngeal mirror. One to three such applications at 



588 



DISEASES OF THE LARYNX 



intervals of from three to five minutes generally induce local anesthesia 
profound enough to permit of an operation. Cocaine is not well toler- 
ated by children, and should be used with caution. Anesthesia is not 
necessary for simple inspection of the larynx in children if they are 
properly held. 

Posture of the Patient.— The sitting posture is generally used. The 
patient should be seated upon a stool 8 inches high; an assistant, sitting 
behind the patient, should hold his head forward, the head rotating back- 



Fig. 357 




Direct laryngoscopy with Jackson's self -illuminated tube spatula: a, electric cord supplying the 
lamp at the distal end of the spatula; b, the conduit for the electric cord; c, the tip of the tube 
spatula holding the epiglottis forward against the base of the tongue; d, the conduit for the 
removal of the secretions and blood from the larynx during examinations and operations by 
direct laryngoscopy. 

ward on the occipito-atlantal joint, to bring the mouth in line with the 
axis of the trachea. The patient's inclination is to throw his head and 
neck backward. This defeats the whole object. The head and neck 
should be pushed as far forward as possible. The assistant should also 
steady the mouth gag in the patient's mouth. The surgeon should retract 
the upper lip with the index finger to prevent its being injured between 
the upper teeth and the slide speculum. The surgeon should stand in 



FOREIGN BODIES IN THE LARYNX 589 

front of and over the patient, with his eye in line with the tube spatula 
and the larynx (Fig. 357). 

Introduction of the Slide Speculum. — Pass the instrument into the throat 
until the distal end of the instrument is behind the tip of the epiglottis. 
Then draw the epiglottis forward against the base of the tongue, as shown 
in Fig. 357. If the spatula is placed too low, against the cricoid ring, 
the patient has a pronounced sense of suffocation; whereas if the instru- 
ment is withdrawn a little higher the dyspnea is relieved and the patient 
breathes with a "brassy" tubular sound. 

Examination through the Slide Speculum. — Forcibly draw the epiglottis 
forward against the base of the tongue to bring the anterior portion of 
the larynx into view\ This is very difficult to do in some patients and 
comparatively easy in others. If the illuminated instrument is used, the 
light should be turned on before introducing it into the mouth. If a 
non-illuminated tube is used, a Kierstein head lamp should be utilized 
to illuminate the larynx. 

Upper Tracheobronchoscopy. — Upper tracheobronchoscopy is used for 
diagnostic and therapeutic purposes. By it the condition of the trachea, 
bronchi, and bronchioles may be observed, and treated by cotton-wound 
applicators moistened with the medicine. Jackson has observed and 
successfully treated ulcers of the trachea by upper tracheobronchoscopy. 
Persistent cough that resisted all other methods of treatment was quickly 
cured when the diseased tracheal mucous membrane was brushed with 
a mild solution of the nitrate of silver, argyrol, etc., via the tracheobron- 
choscopy Foreign bodies in the trachea, bronchus, or one of the smaller 
bronchioles may be diagnosticated and removed through the tracheo- 
bronchoscopy 

Preparation of the Patient. — If a general anesthetic is to be given, the 
patient should be prepared as for a major surgical operation if time 
permits. 

Anesthesia. — A general anesthetic, preferably ether, should be admin- 
istered. The larynx, trachea, and bronchi should also be brushed with a 
20 per cent, solution of cocaine. The larynx may be brushed with cocaine 
before the introduction of the bronchoscope, and the trachea and bronchi 
as the tube is passed downward. The local anesthetic should not be 
administered until the general has attained its full effect, as it is safer to 
preserve the reflexes, so that the patient will aid in disposing of the secre- 
tions; otherwise, aspiration pneumonia may result. The use of cocaine 
in the larynx and trachea prevents the reflex phenomena due to irritation 
of the vagus nerve. After the bronchoscope is introduced the anesthetic 
should be given through the tube or by rectum after Cunningham's 
method. Dr. T. Drysdale Buchanan has devised an anesthetic attach- 
ment (Fig. 359) to the Jackson bronchoscope, and Dr. Jackson now 
uses this. The anesthetic tube ends in the proximal end of the tube and 
chloroform is blown in from a dosimetric apparatus at each inspiration 
of the patient. The anesthetic is started with a mask in the ordinary 
way and preferably with ether. The new method requires an anesthetist 
familiar with the apparatus. A Brophy vaporizer may be used. 



590 



DISEASES OF THE LARYNX 



Position of the Patient's Head. — Have an assistant seated on a 
stool at the right side of the head of the patient, with his left foot on a 
low stool. The patient's head and neck are drawn beyond the end of 
the table, and are supported and controlled by the assistant. His right 
arm is passed beneath the neck of the patient, the hand grasping the 



Fig. 358 




mouth gag and side of the face. The assistant's left arm rests upon his 
left knee, and his hand supports the patient's head. The head and neck 
are thus under the complete control of the assistant (Fig. 352). By 
raising his right arm, the neck is raised; by raising the left hand, the 



/f^ 



Fig. 359 




Dr. T. Drysdale Buchanan's anesthetizing dosimetric attachment for Jackson's bronchoscope. 
The chloroform is delivered into the proximal end of the bronchoscope at each inspiration. 



head is raised, and by reversing the movements of the arm and hand, the 
opposite effects are produced. With the right and left hands the head 
may be rotated on its vertebral axis. The foot of the table should be 
15 inches lower than the head, and the top of the footstool 26 inches 
lower than the top of the table. 



FOREIGN BODIES IN THE LARYNX 



591 



Introducing the Slide Speculum. — The slide speculum should be 
introduced to expose the chink of the glottis while the tracheobron- 
choscope (Fig. 360) is being introduced. This procedure is identical 
with that described in the section on Direct Laryngoscopy, the only 
difference being the recumbent posture of the patient and the use of the 
slide speculum spatula. Jackson's slide speculum (Fig. 351) is so con- 
structed that it may be easily removed after the tracheobronchoscope has 
entered the trachea. 



Fig. 360 




Jackson's self -illuminated tracheobronchoscope. 



Introducing the Tracheobronchoscope. — Having properly introduced 
the slide speculum and exposed the cords of the larynx to view through 
it, the tracheobronchoscope is introduced through the tube spatula to 
the larynx. The light is turned on and regulated by an assistant before 
handing it to the operator and the operator's eye is placed at the proximal 
end of the tracheobronchoscope to watch the respiratory movements of 
the vocal cords. The tracheobronchoscope should be passed through 
the glottis during an inspiratory movement of the vocal cords, as they 
are separated at this time. 

Having passed the vocal cords and a good distance into the trachea, 
the slide speculum should be separated and removed from the mouth 
after the thimble gag (Fig. 371) has been inserted to prevent the patient 
biting the bronchoscope. The slide speculum being of thick metal 
does not need it. Wide gagging renders exposure of the larynx and 
passing a bronchoscope almost impossible. 

The tracheobronchoscope resting in the angle of the mouth and trachea 
should be pushed downward (cocaine being applied to the mucous mem- 
brane with a long sponge holder) until it reaches the foreign body, 
morbid process, or the bifurcation of the trachea. The tracheobroncho- 
scope should rest in the right angle of the mouth. The entire head is 
moved to the right when the left bronchus is to be entered, and to the 
left when the right bronchus is to be entered. The operator should 
constantly guard the upper lip of the patient with his index finger, to 
prevent it being pinched between the upper teeth and the broncho- 
scope, and for this purpose and the steadying of the bronchoscope the 



592 



DISEASES OF THE LARYNX 



little and adjoining finger of the left hand are kept in the patient's mouth 
while the thumb and index fingers steady the bronchoscope. 



Fig. 361 



Fig. 362 





Jackson's safety-pin forceps for holding the ring of an 
open safety-pin securely while the forceps carries the pin 
down into the stomach, where the pin is turned over for 
safe removal. Employed in cases of open safety-pin 
lodged point up in the esophagus. 

Fig. 363 




ft 




< 

_J 
_J 
O 

o 



1 



Safety-pin closer. 



Mosher's safety-pin holder. 



Having entered the right or left bronchus, the tube is passed down- 
ward, the operator watching for the secondary bronchi, morbid lesion, or 



FOREIGN BODIES IN THE LARYNX 



593 



the foreign body. By using the smallest-sized bronchoscope the terminal 
bronchioles may be explored for abscess or other morbid lesion, and if 
the diseased area is not accessible to bronchoscopic treatment, it may be 
accurately diagnosticated and located and operated through the chest 
wall by a general surgeon. 

The Removal of the Secretions and Blood. — In cases of very excessive 
secretion the secretions and blood may be removed with Jackson's 
pump or aspirator (Fig. 354), which is attached to the conduit for this 
purpose. An assistant should have entire charge of the aspirator, and use 
it as directed by the operator. Ordinarily mounted long sponge holders 
are used to remove the secretions. According to Ingals, the preliminary 
use of atropine prevents excessive secretions. It also guards against reflex 
shock. According to Jackson, morphine lessens secretion very much, 
and it also lessens the cough, but is not as safe as atropine, because it 
prevents the patient ridding his air passages of secretions and infective 
materials after the bronchoscopy is over. 



Fig. 364 



Fig. 365 





Jackson's forceps, curved jaws. 



Jackson's forceps, cupped jaws. 




Specimen forceps tip to fit universal handle. The side jaw will bite into a flat lateral wall. 
The cross forms the bottom of a basket to hold the tissue removed. 



The Removal of Foreign Bodies. — Variously shaped forceps, hooks, 
screws, etc., are used to remove foreign bodies (Figs. 361 to 365). 

Topical Applications. — Ulcers and other local morbid lesions of the 
mucous membrane of the trachea and bronchi may be brushed with a 
weak solution of the nitrate of silver through the tracheobronchoscope. 

Remarks. — The trachea and bronchi are elastic and expansile, and 
tolerate the straightening and dilatation with the bronchoscope. 

The illuminated tubes should be boiled after the electric light carrier 
is removed. The light carriers should be immersed in alcohol. The 
unilluminated tubes should not be boiled, as the lustre of the interior 
of the tube is thus destroyed, and its capacity to carry the reflected rays 
from the head lamp is diminished. 

Do not use instruments in lower bronchoscopy that have just been 
used in upper bronchoscopy. Have freshly sterilized instruments ready 
for the purpose. Have sterile lamps in a sterile tube ready for use should 
a lamp burn out. 

The patient's head and face should be prepared as for a major opera- 
38 



594 DISEASES OF THE LARYNX 

tion about the head. The teeth and mouth should be cleansed with 
soap and alcohol. The operator and assistants should be dressed in sterile 
gowns and caps, a precaution especially necessary in handling the long 
instruments. 

The patient should be allowed to sit up as soon as possible, to prevent 
the occurrence of pneumonia. 

Lower Tracheobronchoscopy. — Lower tracheobronchoscopy consists in 
introducing the tracheobronchoscope through a tracheotomy wound, as 
shown in Plate XV. 

Indications. — Lower tracheobronchoscopy is indicated when direct 
laryngoscopy or upper tracheobronchoscopy fails. A larger tube may 
be used in lower bronchoscopy, an advantage in removing large foreign 
bodies, though Jackson states that he has never yet performed a trache- 
otomy for the purpose of lower bronchoscopy, having always been able 
to remove the- foreign body through the glottis. He believes that any 
foreign body that has gone down through the glottis can be and should 
be removed by the same route. 

Position of the Patient. — Primary lower bronchoscopy should always 
be done in the dorsal position, as tracheotomy is to be performed. The 
patient should be placed in Rose's position, with the head extended 
beyond the end of the table. 

Fig. 367 



Trousseau's dilator. 

Low Tracheotomy. — Low tracheotomy should be performed, as the chin 
is thus farther removed from the operative field and is not so much in the 
way of the long instruments. The tracheobronchoscope may, however, 
be introduced through a high tracheotomy wound. 

Stop all bleeding before introducing the tracheobronchoscope. 

The trachea should be swabbed with a 20 per cent, solution of cocaine 
through Trousseau's dilator (Fig. 367). 

If the right bronchus is to be entered, have the patient's head turned 
to the right and vice versa. 

Introduction of the Tracheobronchoscope. — Jackson's illuminated short 
tracheobronchoscope should be introduced through the tracheotomy 
wound, the operator's eye being at the proximal end of the tube watching 
for the bifurcation of the trachea (Plate XV). The end of the broncho- 
scope usually lodges against the bifurcation, so that both bronchi are 
visible. Lateral pressure in either direction will allow the tube to pass 
into one of the bronchi. The moment the tube enters the bronchus, 
cough is excited. A cotton-wound applicator moistened with a 10 per 



FOREIGN BODIES IN THE LARYNX 



595 



cent, solution of cocaine should be applied through the tube and the tube 
passed to the secondary bifurcation (Fig. 368, SL). When a secondary 
bronchus is entered cough is again excited, and cocaine should be applied 
as before. It is impossible to maintain anesthesia deep enough to abolish 
entirely the cough reflex for any length of time, unless rectal anesthesia 
is used, and even then it is not advisable to abolish all the reflexes, as 
the patient is thereby subjected to the danger of aspiration pneumonia. 
Having introduced the tracheobronchoscope, the foreign body and 
morbid lesions should be studied, treated, or removed. 



Fig. 368 



Fig. 369 




Tracheobronchial tree: LM, left main bron- 
chus; SL, superior lobe bronchus; ML, middle 
lobe bronchus; IL, inferior lobe bronchus. 
(Jackson.) 




Pouch of the posterior wall of the hypopharynx. 



After-treatment. — The tracheotomy wound should not be sutured 
except at its upper and lower angles. The tracheotomy tube should be 
worn for a few days, but should be abandoned before the patient leaves 
the hospital. The tracheotomy wound should be cleansed every three 
hours with a warm 1 to 5000 bichloride solution. The wound should 
heal from the bottom, beginning with the severed tracheal rings. If 
the fleshy portion of the wound tends to heal first, it should be pre- 
vented. 

Diverticulum or Pouch of the Hupopharyiix. — The inferior constrictor 
muscle of the pharynx forms the posterior and lateral walls of the hypo- 
pharynx, and it is in the median or posterior wall of this muscle that the 
pouching occurs. The lower fibers are attached to the cricoid cartilage 
and extend in a horizontal direction. The remainder of the muscle 
fibers radiate in an upward and median direction (Fig. 369), and it is in 
the central and lower portion of this part of the muscle that the pouching 
occurs. Various theories have been advanced to explain the pouching 



596 DISEASES OF THE LARYNX 

in this region, but the one advanced by Wilson is probably correct, 
namely, the occasional congenital absence of muscle fibers in this region. 
He has found the muscle fibers absent in a considerable percentage of the 
cadavers examined by him. When the pouch is present it may be the 
seat of lodgement for a bolus of food or a foreign body. When such a 
condition is present, it may be examined by direct pharyngoscopy with 
the Killian or Jackson tube spatula and the food or foreign body removed 
through the same instrument. 

Spasm of the inferior constrictor muscle, especially the circular portion 
which forms the mouth of the esophagus, may occur and prevent the 
swallowing of food for a few hours or days. 

In attempting esophagoscopy in a patient in whom the pouch is present, 
the esophagoscope may enter the pouch and lead to the erroneous im- 
pression that the esophagus is closed by stricture. A careful observation 
and manipulation should lead to a correct diagnosis. 



ESOPHAGOSCOPY; FOREIGN BODIES IN AND STRICTURES OF 
THE ESOPHAGUS 

The examination of the esophagus through the mouth is now an 
established procedure, and should be considered in connection with 
bronchoscopy, as foreign bodies may lodge in either tube. The differen- 
tial diagnosis between a foreign body in the trachea or bronchi and the 
esophagus must, therefore, be made. Not only this, but the foreign body 
should be removed, whether it is in the bronchi, the trachea, or the 
esophagus. A brief description of esophagoscopy will, therefore, be 
given in this work. 

The sizes of tubes required, according to Chevalier Jackson, are, for 
infants, 7 mm., and for adults, 10 mm. in diameter. 

The normal appearance of the esophageal lumen with the Jackson 
self-illuminated tubes is a whitish grayish pink, in strong contrast to the 
white and red rings of the tracheal membrane. 

Examination of the Upper End of the Esophagus.— This is the 
easiest of all the examinations with the straight tubes, and is accom- 
plished by the same technique as described under Direct Laryngoscopy. 
According to Jackson, the slide spatula speculum (Fig. 351) should 
be passed back of the base of the tongue until the epiglottis appears, 
after having cocainized the introitus esophagi with a 10 per cent, solu- 
tion. Having engaged the tip of the epiglottis, a straight cotton-wound 
applicator, dipped in a 10 per cent, solution of cocaine, should be passed 
through the slide speculum and applied to the epiglottis, the laryngeal 
and the esophageal orifices; a few minutes should be allowed for anes- 
thesia to supervene. The speculum is then passed down back of the 
epiglottis and the cricoid cartilage, and lifted forward against the base 
of the tongue. The larynx and the esophageal depression are thus 
brought into view. The spatular end of the speculum is inserted into 
the esophageal depression to a point below the arytenoid cartilages. 



ESOPHAGOSCOPY 



597 



and far enough to engage the posterior portion of the cricoid cartilage. 
The cartilage should then be lifted forward, thus exposing the pyriform 
fossa? and the esophageal lumen. 



ESOPHAGOSCOPY 

According to Dr. Chevalier Jackson, preliminary to passing a tube 
into the lumen of the esophagus the upper end of the esophagus should 
be examined, as described in the preceding paragraph, to learn the 
pathological conditions present in this region. This procedure will 
prevent the making of a false passage through an ulcerated surface and 
will locate a foreign body if present at the entrance of the esophagus. 
In passing the long tube extreme gentleness should be practised. If the 
tube does not readily pass, it is either not correctly placed or it is im- 
properly directed. The tube should be lubricated with sterile vaseline. 
The proximal end should be held lightly with the right hand, the handle 
directed horizontally to the right. The forefinger of the left hand is 
passed into the right glosso-epiglottic fossa, posteriorly to the lateral 
glosso-epiglottic fold and posteriorly to the tense pharyngo-epiglottic 
fold, and, if possible, into the right pyriform sinus. 



Fig. 370 



Fig. 371 




Thimble gag or bite block for bronchoscopy 
and esophagoscopy. 



(O) 



Schema showing relation of the cricoid 
cartilage (the circle) to the posterior hypo- 
pharyngeal wall, in the dorsally recumbent 
patient, observer looking down the esoph- 
agus. The pyriform sinuses are at the 
positions marked X. 



The tube should then be made to follow the same route, while the 
finger slides toward the median line and lifts the tongue and anterior 
pharyngeal tissues upward (dorsal decubitus). When the cricoid carti- 
lage can be reached, which is possible only in children, it is better to 
lift upon it directly rather than upon the soft tissues. When possible, 
as it usually is in adults, the cartilage should be lifted indirectly by 
traction upon the tissues at the extreme point reachable with the finger, 
often the right glosso-epiglottic fossa. With practice the whole instru- 
ment is pointed by the operator's general sense of direction into the axis 
of the pyriform sinus, just as a billiard cue is used. (Jackson.) 

The head of the patient should be held in extreme extension with the 
mouth widely open, as shown in Fig. 357. 



598 



DISEASES OF THE LARYNX 



After the introiius is passed the obturator is removed, and the cord 
is attached to the light carrier by the bayonet fitting. The tube must be 
guided by the eye so as to follow the esophageal lumen by sight. In 
the thorax the lumen opens up at each inspiration, when the axis is 
easily followed. After passing the introiius, the head of the patient should 
be raised slightly to prevent the tube pressing on the trachea. The obtu- 
rator should never be used in case of foreign bodies, as the foreign body 
may be overridden. The right pyriform sinus is found by sight and the 
general sense of direction and the well-greased esophagoscope is insin- 
uated through it. 



Fig. 372 



Fig. 373 





The probable position assumed by a penny 
when lodged in the subglottic space. 



The position assumed by a penny, as shown 
by skiagraphy, when lodged in the mouth of 
the esophagus of a child, aged three years. 
(Author's case.) 



The entire lumen of the esophagus may be examined for stricture or 
other pathological lesion, and for foreign bodies. When a foreign body 
is found it may be removed as by bronchoscopy. By using a longer tube 
almost the entire surface of the stomach may also be inspected with 
great clearness of illumination with Jackson's self-illuminated gastro- 
scope. 

In one of my cases the skiagrapher reported the foreign body, a penny, 
to be located at the bifurcation of the trachea. As it was impossible for 
me to get to the studio to examine the plate, I acted upon his diagnosis 
and attempted to locate the foreign body in the trachea. At one time I 
passed the tube into the esophagus and heard a slight metallic click. 
Further search failed to elicit the metallic sound. When I viewed the 
skiagraphic plate a few days later I found the shadow of the penny on a 
level with the cricoid cartilage, instead of at the bifurcation of the trachea, 
as reported by the skiagrapher. Nine days after the attempted removal 



INSTRUMENTS FOR LARYNGOSCOPY AND ESOPHAGOSCOPY 599 

by bronchoscopy the penny was passed per rectum, thus showing the 
penny to have been in the upper portion of the esophagus, from which 
place it was probably dislodged at the time I heard the metallic click. 
Another point of diagnostic interest in this case was the position of the 
penny. Its flat surface stood at right angles to the vocal cords, a fact 
which immediately attracted my attention when I saw the plate a few 
days later. Had the penny been in the subglottic space, its edge would 
probably have presented anteriorly. The location and position of the 
penny led me to inform the parents that it was not in the trachea, but 
was in the upper part of the esophagus at the time the skiagraphic plate 
was made. This diagnosis was later verified by the passage of the penny 
(Figs. 372 and 373). 



INSTRUMENTS FOR DIRECT LARYNGOSCOPY, BRONCHOSCOPY 
AND ESOPHAGOSCOPY 

Dr. Jackson has reduced his tubal armamentarium to four tubes and 
two slide speculums. It is impracticable to have one tube for adults 
and children, or the same tube for the esophagus and the bronchi. This 
means one bronchoscope for adults and one for children; one esophago- 
scope for adults and one for children. A good working set would be 
the following : 

1 bronchoscope, 5 mm. by 30 cm., for children. 

1 bronchoscope, 7 mm. by 40 cm., for adults. 

1 esophagoscope, 10 mm. by 53 cm., for adults. 

1 esophagoscope, 7 mm. by 45 cm., for children. 

1 adult's slide speculum. 

1 child's slide speculum. 

1 aspirator for the esophagoscopes. 

1 specimen forceps, long and short. 

1 foreign-body forceps. 

3 Coolidge sponge holders with Jackson's long collar. 

1 Sajous' cotton-holding laryngeal forceps, for cocainizing the pharynx 
and upper laryngeal orifice. 

1 double bronchoscopic battery. 

An extra large adult size bronchoscope, 9 mm. by 40 cm., and an extra 
small infant size, 4 mm. by 30 cm., are very useful. 



PAET IV 
THE EAR 



CHAPTER XXXII 

THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR 

The organ of hearing is divisible into (a) the external ear, (b) the 
middle ear, and (c) the internal ear. 

THE EXTERNAL EAR 

From a clinical point of view the auricle is of interest on account of the 
destructive inflammatory processes which attack its cartilaginous frame- 
work and the perichondrium covering it. Perichondritis and chondritis 
of the auricle occurring in the insane from traumatism has been fre- 
quently observed and reported (Fig. 395). Perichondritis following the 
mastoid operation occasionally occurs. I have seen but one case in my 
practice, and it developed several weeks after the mastoid operation; the 
exciting cause was undoubtedly the influenza bacillus, as it followed an 
attack of la grippe. In performing the plastic operation upon the meatus, 
that is, in making the Koerner, Panse, Siebenmann, or the Ballance 
incisions, the cartilage of the auricle is included ; hence, it is necessary to 
exercise great care as to surgical cleanliness, otherwise infection of the 
perichondrium and cartilage may occur. 

The external auditory meatus is divisible into a cartilaginous and an 
osseous portion. The cartilaginous portion of the meatus (the auricular 
extension) is attached to the osseous or deeper portion by bands of 
fibrous tissue. The superior and posterior walls of the cartilaginous 
meatus are thinner than the anterior and inferior walls. The inferior 
wall extends deeper along the floor of the meatus than the other walls, 
and is known as the processus triangularis. The anterior wall of the 
cartilaginous meatus is crossed by two or three fissures, which are filled 
with connective tissue and a few muscle fibers. These fissures are 
called the fissures of Santorini, and they render the auricle more movable. 
They are of clinical importance, first, because they afford an outlet for 
the discharge of pus into the meatus in deep abscess of the parotid gland, 
and secondly, because they render the auricle more elastic and thus 
permit it to be turned on the cheek during the mastoid operation. 

(601) 



602 THE EAR 

In the newborn the meatus is fibrous throughout its entire length, 
and its walls are collapsed and in apposition. Bone salts are gradually 
deposited and the canal assumes its patulous condition. 

The sebaceous glands are limited to the cartilaginous portion of the 
meatus, hence furunculosis of the meatus is confined to this area. The 
beginner in otology is sometimes confused in making a differential diag- 
nosis between acute suppurative mastoiditis with bulging of the post- 
superior wall, and furunculosis of the cartilaginous meatus. In the 
first instance, the bulging is in the bony meatus close to the drumhead, 
and the auricle is not tender or sensitive upon manipulation. In the 
second instance, the bulging is more external in the cartilaginous meatus, 
and the auricle is extremely sensitive upon manipulation. The sensi- 
tiveness of the auricle in furunculosis is due to the fact that the inflamma- 
tory reaction attending the furuncle or boil has extended by continuity 
of tissue from the cartilage of the meatus to the cartilage of the auricle, 
and thereby renders the nerve fibers of the auricle exquisitely sensitive. 



THE MIDDLE EAR 

The membrana tympani forms the outer wall of the middle ear. It is 
a composite membrane of three layers: the outer one being a reflection 
of the skin of the meatus, the middle one being fibrous tissue, and the 
inner a reflection of the mucous membrane of the middle ear. The 
handle of the malleus is embedded within these structures, hence the 
sound waves impinging upon the eardrum are transmitted to the handle 
of the malleus, and thence to the incus and stapes, where the foot plate 
transmits them to the sound-perception apparatus. 

The membrana tympani is of clinical importance chiefly on account of 
the various changes in its appearance in diseased conditions of the middle 
ear. These changes are, therefore, of diagnostic value. In order to 
appreciate fully the abnormal appearances of the eardrum, it is first 
necessary to know the normal characteristics. A normal drumhead is 
characterized by the presence of the handle of the malleus, the short 
process of the malleus, the triangular cone of light, the anterior and 
posterior folds, and a faint view of the long process of the incus seen 
through the semitransparent pearly gray eardrum. 

When the Eustachian tube is closed, the air within the middle-ear 
cavity becomes rarefied by the gradual absorption of the oxygen into the 
blood of the surrounding tissues. As a result of the negative pressure 
thus brought about, the eardrum is pushed inward — that is, the eardrum 
is retracted. This changes the contour of the eardrum as viewed through 
the external auditory meatus. The cone of light is broken or altogether 
lost, the handle of the malleus is drawn inward and is foreshortened, 
the short process of the malleus projects more prominently toward the 
observer's eye, and the anterior and posterior folds which arise from the 
short process are accentuated. 

In retraction due to obstruction of the Eustachian tube, the membrana 



THE EUSTACHIAN TUBE 603 

tynipani is regular or uniform throughout its entire area, with the excep- 
tion of the part containing the malleus. If the retraction is due to an 
adhesion to the inner wall of the tympanic cavity, the membrane is 
irregularly retracted. The membrana tympani, upon suction with 
Siegle's otoscope, remains fixed at the point of adhesion, and is dis- 
tended in other areas, giving a blistered appearance. 



PERFORATION OF THE MEMBRANA TYMPANI 

The clinical significance of perforation of the membrana tympani when 
due to middle-ear disease is somewhat dependent upon whether it is 
marginal or central in location. When marginal, it usually signifies 
bone necrosis; and when central (away from the margin), it signifies a 
simple middle-ear suppuration without bone necrosis. 

Its significance is still further differentiated by its exact location; that 
is, if it is marginal the bone necrosis is in the immediate vicinity of the 
marginal perforation. If, for instance, the perforation is in the margin 
of Shrapnell's membrane (membrana flaccida), immediately above the 
short process of the malleus, the tegmen antri is necrotic; if it is in the 
post-superior margin of the eardrum (the part nearest to the antrum), 
the mastoid antrum is necrosed. 

The point to be borne in mind is that the perforation is secondary to 
the bone necrosis, the necrotic process extending from the ear cavities 
to the eardrum. Its clinical significance is, therefore, an index to a 
preexisting morbid process in the tympanic cavities, the focal point of 
which is in the neighborhood of the perforation. Leutert, Zaufal, the 
author, and others have called attention to the significance of the fore- 
going facts. 

The further elaboration of the clinical significance of perforations of 
the eardrum is given in Fig. 417. 



THE EUSTACHIAN TUBE 

The second and most common avenue of approach to the middle-ear 
cavity is through the Eustachian tube. It is through this channel that 
nearly all middle-ear diseases invade the middle-ear cavity. The tube 
is about 36 mm. long, the pharyngeal opening being about 15 mm. 
lower than the tympanic opening. The tympanic opening corresponds 
to the anterosuperior quadrant of the eardrum, hence it is not in the 
most dependent portion of the cavity. This does not interfere with 
drainage under normal conditions, as the cilia? of the epithelium of the 
tympanic cavity sweep the secretions to the opening of the tube and 
through it to its pharyngeal opening. If, however, the cilia? are impaired 
in their functional activity by an inflammatory or other morbid process, 
the elevated position of the tympanic orifice of the tube materially 
interferes with the drainage. Under these conditions the secretions are 



604 THE EAR 

retained, decomposition follows, and further irritation of the mucous 
membrane results. 

The tympanic end of the tube has an osseous framework, and is about 
12 mm. long. The pharyngeal end of the tube has a cartilaginous and 
membranous framework, and is about 24 mm. long. The tube is trumpet- 
shaped at both extremities, and is narrowest at the junction of the osseous 
and cartilaginous portions. This is known as the isthmus. The frame- 
work is lined with mucous membrane which is covered with ciliated 
epithelium, which carries the secretions toward the pharyngeal orifice. 

Under ordinary conditions, the membranous walls of the tube are in a 
state of collapse, and only open when certain palatal muscles are con- 
tracted. Yawning and swallowing cause these muscles to contract, and 
air is thus admitted into the tympanic cavity. 

The muscles regulating the patency of the pharyngeal orifice of the 
tube are the tensor veli palati and the levator palati; they also elevate the 
soft palate and assist in approximating it against the posterior wall of 
the pharynx in the act of swallowing. * As the superior ends of the muscles 
are attached to the cartilaginous lip and to the membranous portion of 
the tube, and the inferior end to the soft palate, it is obvious that the 
contraction of the muscles will produce a twofold result — namely, the 
pharyngeal orifice of the tube is opened and the soft palate is elevated. 

When, for any reason, the act of swallowing does not open the tube 
sufficiently to admit air into the tympanic cavity, the oxygen is absorbed 
from the contained air by the blood in the surrounding tissues, and a 
partial vacuum, or negative pressure, results. The blood in the sur- 
rounding tissues is drawn to the parts by the negative pressure, and 
congestion results. The retained secretions undergo decomposition 
and irritate the lining mucous membrane. The hyperemia induces 
overnutrition. As a result of the combined irritation and increased 
nutrition the mucous membrane becomes thickened, either by hyper- 
trophy or hyperplasia. The secretions are not only retained in excesive 
quantity, but are changed in character. This condition is known as 
middle-ear and tubal catarrh. . 

Anything that obstructs the flow of secretions of the Eustachian tube 
predisposes the mucous membrane of the tube and middle ear to infec- 
tion and inflammation. The two great underlying principles relating 
to the etiology of inflammation of mucous membrane lined cavities are: 
(a) The exciting cause of inflammation is almost always a pathogenic 
microorganism. The microorganism is powerless to grow upon healthy 
tissue, hence the second great underlying principle relates to the con- 
ditions which favor their growth, (b) The predisposing cause is usually 
an obstructive lesion interfering with the drainage and ventilation of 
the cavity, thereby lowering the resistance of the tissues. The patho- 
genic microorganisms then flourish, and with their toxins excite the 
reaction of inflammation. 

The action of the tensor and levator veli palati muscles is so intimately 
associated with that of the muscles of the palate and pharynx, that it is 
somewhat difficult to estimate the influence of the other muscles on the 



THE EUSTACHIAN TUBE 



605 



patency of the tubes. The pharyngopalatinus (posterior pillar of the 
fauces) has its upper attachment in the soft palate, and it contracts 
during deglutition, and thus indirectly exerts a tensive action upon the 
tubal muscles. In inflammatory processes involving the tonsils and 
the faucial pillars, the swollen condition of the palatopharyngeus muscle 
indirectly interferes with the action of the tubal muscles. In this way, 
disease of the tonsil causes tubal and middle-ear disease; that is, drainage 
and ventilation are interfered with. The microorganisms causing the 
tonsillar disease find a lowered resistance of the tubal membrane, grow 
there, and cause catarrhal or suppurative inflammation. 

The anterior wall of the pharyngeal end of the tube is membranous, 
while the upper and posterior walls are cartilaginous. The tensor and 
levator veli palati muscles are attached to the membranous portion of the 
tube, hence when they contract the tube is opened to its isthmus. 



Fig. 374 




Showing a method of catheterization: a, the ring indicating the direction of the tip of the cath- 
eter; b, the posterior wall of the pharynx; c, c, the ridge forming the posterior lip of the mouth 
of the Eustachian tube; /, f, Rosenmuller's fossa; b, d, e, the route traversed by the tip of the cath- 
eter to enter the mouth of the Eustachian tube. 



Much has been written concerning the normal patency of the Eusta- 
chian tube, and the preponderance of the evidence is in favor of the 
view that it is closed except during the act of deglutition. Politzer's 
experiment, consisting of a vibrating tuning fork held in front of the nose 
shows that it is but faintly heard except during deglutition, thereby 
proving that the tube is closed under ordinary conditions and is open 
during deglutition. This permits of the interchange of air between the 
pharynx and the middle ear, and maintains an equilibrium of pressure 
on the inner and outer surfaces of the membrana tympani. 

The pharyngeal end of the tubal cartilage (posterior and superior 
walls) forms a projecting lip or tubal prominence on the lateral wall of 



606 THE EAR 

the epipharynx. Just behind this is a groove known as Rosenmiiller's 
fossa. The fossa and tubal prominence are the landmarks used in the 
introduction of the Eustachian catheter. The tip of the catheter is first 
lodged in the fossa of Rosenmuller, then drawn forward, gliding down- 
ward and inward over the prominence, and thence upward and outward 
into the tubal orifice (Fig. 374). 

To inflate the tube and middle ear, the compressed air should be 
applied at the beginning of the act of deglutition, as the tubal muscles are 
then contracted and the tube open. The Eustachian tube of an infant 
is shorter, straighter, and more easily inflated than that of an adult. 
In an adult the tube is sharply bent at the isthmus, whereas in an infant 
the tube is nearly straight. A lower degree of air pressure should, there- 
fore, be used for infants than for adults. Earache in infants and young 
children is often quickly relieved by inflation, as it is due to tubal con- 
gestion and obstruction, or to a plug of tenacious mucus in the lumen 
of the tube. 



THE TYMPANIC CAVITY; TYMPANUM; CAVUM TYMPANI 

The tympanic cavity is the space between the tympanic orifice of 
the Eustachian tube and the mastoid antrum. Its lining mucous mem- 
brane is continuous with that of the Eustachian tube, and extends to the 
antrum and mastoid cells. It is covered with ciliated epithelium, the 
wave-like motion of which carries the secretion to the Eustachian tube. 

The upper wall (tegmen tympani) of the tympanic cavity forms a 
portion of the floor of the middle fossa of the cranial cavity; the outer 
wall is composed of the eardrum, and in its upper portion (outer wall 
of the attic) of bone. The wedge of bone forming the outer wall of the 
attic should be removed in the radical mastoid operation to fully expose 
this space to inspection and treatment during and after the operation. 
The inner wall of the tympanic cavity is contiguous to the outer wall 
of the cochlea and vestibule; the posterior wall separates the tympanic 
cavity from the antrum and mastoid cells; the anterior wall is very thin 
and covers the internal carotid artery; and the lower wall separates the 
tympanic cavity from the jugular bulb. The facial nerve runs across 
the upper and posterior wall and is usually enclosed in a bony covering, 
though numerous instances are on record in which the bony covering 
was absent. 

The foregoing description of the relations of the walls of the tympanic 
cavity to the contiguous vital organs is of great clinical significance in 
the middle ear and mastoid infections and inflammations. 

Contents of the Tympanic Cavity.— The tympanic cavity contains 
the chain of ossicles, the tympanic muscles, and the chorda tympani 
nerve. The handle of the malleus is attached to the membrana tym- 
pani, and the foot plate of the stapes is attached to the membrane 
of the oval window. The incus is suspended between the malleus and 
stapes, and completes the anatomical connection between the membrana 



THE TYMPANIC CAVITY 607 

tympani and the labyrinth. The chain of ossicles transmits the sound 
waves from the membrana tympani to the labyrinth, though there is little 
doubt that some waves are transmitted through the air in the tympanum 
to the round or oval window without the intervention of the ossicles. 
I recall one patient on whom I did a radical mastoid operation, removing 
the malleus and incus, who heard whispered speech at ten feet, showing 
that good hearing is possible though all the ossicles were removed except 
the stapes. 

The Chain of Ossicles and the Membrane of the Oval Window. — It is 
shown by the case just cited that all the receiving apparatus may be 
removed except the contents of the oval window without greatly im- 
pairing the hearing, though this is exceptional. Orientation of hearing 
is greatly diminished, as is also the faculty of keying the perception 
apparatus to catch sounds accurately. The tensor tympani and the 
stapedius muscles are rendered ineffective by the removal of the malleus 
and incus, hence the ear has lost its focussing apparatus. The mem- 
brana tympani receives a larger number of sound waves than the foot 
plate of the stapes, hence the hearing is more acute with the eardrum 
and the ossicles intact than it is without them. 

A Physiological Law. — It may be laid down as a physiological law 
that anything that interferes with the normal tension existing between 
the membrana tympani, ossicles, and the contents of the oval window will 
cause tinnitus and deafness. Hence, pathological changes in the eardrum, 
thickening or other change in the mucous membrane which covers the 
ossicles, ankylosis of the ossicles, especially of the foot plate of the stapes, 
as in spongifying of the bony capsule of the labyrinth, etc., result in 
tinnitus and deafness. Catarrhal inflammation of the mucous membrane 
of the middle ear and Eustachian tube induces a negative pressure in 
the tympanic cavity, and disturbs the normal tension between the ear- 
drum and the oval window; the mucous membrane of the walls of the 
tympanic cavity and ossicles is thickened, and tinnitus and deafness 
follow. The inflation of the tympanic cavity in tubal and middle-ear 
catarrh restores (in a degree) the normal tension and decreases the 
congestion of the mucous membrane, and thereby lessens the tinnitus 
and deafness. 

The heads of the malleus and incus and their ligamentous attachments 
to the walls of the tympanic cavity divide the cavity into two compart- 
ments — namely, the atrium, or middle ear proper, and the attic. When 
there is a suppurative process in the attic or the antrum and mastoid 
cells for a considerable time, adhesive bands form and still further 
increase the barrier between the atrium and the attic. The drainage of 
the secretions is blocked, and gives rise to retention and decomposition 
of the secretions and to pressure symptoms, as pain and tenderness. 
Necrosis is also augmented by the increased pressure from the retained 
secretions. Suppuration in the attic, and in the antrum and mastoid 
cells in old chronic cases, is, therefore, a more serious condition than 
suppuration with its focal centre in the atrium. 

The chorda tympani nerve passes through the upper portion of the 



608 THE EAR 

atrium between the nandle of the malleus and the long process of the 
incus, and is usually severed or destroyed in the radical mastoid operation. 
As a consequence, the sense of taste at the base of- the tongue and the 
neighboring parts of the fauces is impaired; indeed, it is perhaps best 
to destroy the nerve, as the irritation during the application of post- 
operative dressings would otherwise excite a disagreeable sense of taste. 

Walls of the Tympanum. — The superior wall, the tegmen tympani, 
is a thin plate of bone forming a portion of the middle fossa of the 
skull, and it is frequently the seat of necrosis in suppurative inflam- 
mation of the middle ear. The necrotic process often extends through it, 
and thus exposes the dura to infective bacteria which may be present. 
Ordinarily a wall of granulation tissue is formed in Nature's effort toward 
repair and protection. Such a perforation may, therefore, exist for years 
without involving the cranial contents. On the other hand, if the secre- 
tion is blocked by the ossicles, their ligaments, and the adhesive bands 
at the floor of the attic, the infective bacteria may be forced through 
the granulation tissue into the cranial cavity and excite meningitis or 
brain abscess. 

One of the strongest arguments against curettage of the attic through 
the external auditory meatus is, that the granulation tissue may be 
removed and the dura exposed to the pathogenic bacteria. The same 
objection does not hold to its removal during the radical mastoid opera- 
tion, as perfect drainage is thereby established. 

The inferior wall or floor of the tympanic cavity is of clinical interest, 
on account of its proximity to the jugular bulb. It is only in exceptional 
cases, however, that the floor is thin, hence the jugular bulb is ordinarily 
in no danger in the curettage of the floor. Occasionally the floor is so 
thin that in curetting granulations from it there is danger of injuring the 
jugular bulb and causing serious or even fatal hemorrhage. When the 
jugular bulb is thrombosed, necrosis of the floor of the tympanic cavity 
may occur, and granulations spring from this point. Granulations of 
the floor of the tympanum in cases of lateral sinus thrombosis are sig- 
nificant of the involvement of the jugular bulb. 

The outer wall of the tympanum is chiefly composed of the membrana 
tympani, though at its upper and lower portions it is composed of bone. 
The bony wall at its upper portion forms the outer wall of the attic, 
or the recessus epitympanicus (Fig. 375). The handle of the malleus 
is embedded in the membrana tympani, as is also the short process, 
located at the upper extremity of the handle. 

The inner wall of the tympanum is of interest because it also forms 
the outer wall of the labyrinth, and because of the presence of impor- 
tant structures concerned in the function of sound conduction (Fig. 
377). The most important of the structures concerned in sound con- 
duction are the oval window (fenestra vestibuli), the stapedius muscle, 
the tensor tympani muscle, and the round window (fenestra cochlea). 
The other important structures are the promontorium, a projection due 
to the beginning of the basil turn of the cochlea; the prominentia canalis 
facialis, which forms the upper and posterior border of the fossula 



THE TYMPANIC CAVITY 609 

fenestrae cochleae, and the prominentia canalis semicircularis lateralis. 
The prominences of the facial nerve canal and of the lateral semicircular 
canal form the median boundary of the attic (recessus epitympanicus), 
and they lie in close relation to the deep portion of the postsuperior wall 
of the external auditory meatus. The removal of this wall in the radical 
mastoid operation is likely to result in injury to these two structures. 
The Stacke protector is sometimes used to protect these structures by 
passing it from the middle ear upward and backward into the aditus 
ad antrum. 

The facial nerve is usually covered by bony tissue, though in excep- 
tional cases it is not. In necrotic processes it is frequently exposed, 
hence extreme caution is necessary in removing the postsuperior wall 
of the meatus, lest the nerve be injured. The nerve comes sharply 
outward from the cranium and then turns downward, forming a rather 
sharp knee, without coming near the mastoid surface. Hence, the outer 
portion of the posterior wall of the meatus may be removed without 
danger of injuring the facial nerve. T. Passmore Berens reported a case 
in which the facial nerve came near the surface, and in which it would 
have been injured if the posterior wall of the meatus had been removed 
as completely as usual. The bone of the postsuperior wall of the meatus 
is often spoken of as a "wedge of bone," from the fact that it is tri- 
angular in shape. The point of the wedge is at its deepest portion, 
while the pole is the external portion. The point of the wedge forms the 
outer wall of the aditus ad antrum, the constriction which marks the 
boundary between the attic and the antrum. 

The malleus and incus are also removed in the radical mastoid opera- 
tion, and the obstruction to the drainage of the mastoid cells and the 
antrum is thus completely removed. The chief objection to the ossicu- 
lectomy alone for the cure of chronic suppurative ear disease is that 
neither is free drainage thereby established, nor is all the morbid material 
removed; that is, the necrosis and granulations are usually present in 
the antrum and cells as well as in the attic, hence the removal of the 
malleus and incus does not give relief except in the attic. If the disease 
is limited, or focalized in the attic, ossiculectomy may be all that is 
necessary to do. 

The Antrum. — The antrum is embryologically a part of the middle 
ear, while the mastoid cells are not. It communicates with the attic 
through the aditus ad antrum. The mastoid cells drain into it. The 
ciliated epithelium lining the cells, antrum, tympanum, and the Eusta- 
chian tube propels the secretions successively through these parts to 
the pharyngeal orifice of the tube. In severe acute inflammation, and 
in prolonged chronic inflammation, the epithelium is denuded in certain 
areas of its ciliae, and the drainage of the secretions is interfered with. 
The superficial destruction of tissue thus started may extend to the deeper 
tissues, as the epithelium, mucous membrane, periosteum, and the bone. 
Necrosis may be thus established. When such extensive destruction 
has become established there is little probability of a cure except by the 
radical, or the meatomastoid operation. 
39 



610 THE EAR 

The Mastoid and Temporal Bone Cells.— A knowledge of the possible 
distribution of the mastoid and temporal bone cells is sometimes a matter 
of extreme importance in the successful treatment of mastoiditis. In 
many chronic cases it is absolutely necessary for the surgeon to remove 
all morbid tissue, and to establish free drainage of the remotest air spaces 
in the temporal bone. The pneumatic cells are not always confined 
to the mastoid process, but may be in the posterior root of the zygoma, 
the squamous plate of the temporal, in front of the external auditory 
meatus and in the posterior wall of the pyramid of the petrous portion 
of the temporal bone. When in the latter position they are not easily 
reached, though as Jansen has shown, they may be exenterated. I have 
seen cases in which pus-discharging cells were in front of the meatus 
with a canal of communication leading to the antrum. Had they not 
been opened and exenterated in the course of the radical operation, 
the operation would have been a failure. Hence, it is necessary in all 
chronic cases to make careful search for pneumatic cells in other regions 
than the mastoid process. In one of Dr. Wale's bony specimens, the 
mastoid cells communicated with the sphenoid sinus. 

The Arteries of the Middle Ear.— The middle ear receives its chief 
blood supply from branches of the internal carotid artery. The branches 
pass backward through the canaliculus carototympanici to the mucous 
membrane of the middle portion of the tympanic cavity: The middle 
meningeal artery sends a branch to the upper portion of the middle 
ear, while the A. stylomastoidea sends a branch to the postinferior portion 
and to the mastoid cells. As all these branches are quite small, they 
have no special clinical significance. 



PHYSIOLOGY OF THE EAR 

I. Membrana Tympani — The eardrum is stretched across the inner 
end of the external meatus, and is elastic enough to undergo considerable 
movement when the air in the meatus is alternately condensed and rare- 
fied with Siegle's otoscope. The membrane is attached to a groove in 
the annulus, the sulcus tympanicus, by an extension of the periosteum, of 
which the middle or fibrous layer is composed. The annulus tympanicus 
does not extend completely around the meatal opening, but is absent at 
the upper portion, the Rivinian segment. The part of the membrane 
attached to the annulus is known as the pars tensa or the membrana 
tensa. 

The part attached to the Rivinian segment is not stretched, but is 
loosely drawn, and is known as ShrapnelPs membrane, the pars flaccida 
or the membrana flaccida. This portion of the membrane forms the 
outer wall of Prussak's space, while the pars tensa forms the lower por- 
tion of the outer wail of the tympanic or middle-ear cavity (Fig. 370). 

The membrana tympanum is not placed perpendicularly across the 
opening of the meatus, but forms an angle of about 140 degrees with the 
postsuperior wall, and one of 45 degrees with the antero-inferior wall. 



PHYSIOLOGY OF THE EAR 611 

This is of clinical importance in the removal of foreign bodies from the 
meatus. 

The function of the membrana tympani is to receive and convey 
sound waves to the chain of ossicles, and thence to the labyrinth. That 
it is not absolutely essential to fair hearing is shown by the fact that 
good hearing is often present when the membrane is perforated or entirely 
absent. The eardrum also protects the tympanic mucous membrane 
from the deleterious effects of the air and from the entrance of morbific 
germs and foreign bodies. 

When the normal tension of the drumhead is disturbed, there is an 
impairment of hearing; hence, any morbid condition of the Eustachian 
tube which interferes with the ventilation of the tympanic cavity, or any 
inflammatory disease of the mucous membrane which interferes with the 
mobility of the ossicular chain, or any morbid condition of the drumhead 
which interferes with its elasticity or motility, will cause more or less 
deafness. 

II. Eustachian Tube.— The function of the Eustachian tube is 
twofold, namely: (a) To ventilate, (b) to drain the tympanic and 
mastoid cavities. When these spaces are healthy, the Eustachian tube 
is adequate for the purpose. When, however, the spaces are inflamed, 
and the secretions are greatly increased in quantity, it is not large enough 
to accommodate the passage of the secretions into the epipharynx. 
When its capacity is thus overtaxed, the retention of the secretions causes 
pressure necrosis in the direction of least resistance, namely, the mem- 
brana tympani. Perforations thus arise in the course of infective inflam- 
mations of the tympanic cavity, the antrum, and mastoid cells. The 
Eustachian tube is generally large enough to carry off the secretions 
from the tympanic cavity, even when in a diseased state; but when in 
addition the antrum and mastoid cells are involved, it is not capable 
of disposing of the secretions, retention occurs, and the pressure symp- 
toms (pain, tenderness, and swelling) of mastoid inflammation ensue. 
If the excess of secretions from the antrum and the mastoid cells are 
diverted from the tympanic cavity, the morbid process tends to subside 
because the tube is large enough to drain the secretions from the tym- 
panic cavity. In other words, the retention of the secretions in any 
cavity tends to foster inflammatory processes in the mucous membrane, 
which may, in time, extend to the periosteum and the bone to which it 
is attached. (See Diseases of the Nasal Accessory Sinuses, the Clinical 
Anatomy of the Tonsils, and Meatomastoid Operation.) 

Tympanic Cavity. — The function of the tympanic cavity and its 
contents is to transmit sound waves to the labyrinth. It also forms a 
channel of communication between the Eustachian tube and the epi- 
pharynx, on the one hand, and the antrum and mastoid cells on the 
other. The cavity is divided into two spaces by the interlocking heads 
of the malleus and incus. The lower space is called the atrium, or the 
middle ear proper, while the upper is called the attic. The attic is 
still further subdivided by the heads of these bones into an inner and 
outer attic. The outer space is divided into an upper and a lower 



612 



THE EAR 



Pig. 375 



space by the external ligament of the malleus (Fig. 375). The lower 
space is called Prussak's space, suppurative inflammation of which is 
difficult to cure. (See Suppuration of Prussak's Space.) 

The inner wall of the tympanic cavity presents two anatomical features 
of physiological and clinical interest, namely, the oval and round win- 
dows. The oval window, the fenestra vestibuli, receives the foot plate 
of the stapes, which is surrounded by the annular ligament and com- 
municates with the vestibule of the labyrinth. The round window opens 
into the cochlea, and the membrane closing it forms an elastic valve to 
relieve the shock to the cochlea in the presence of excessive sound waves. 

Intrinsic Muscles of the Ear. — 
The tensor tympani muscle pulls 
the handle of the malleus inward, 
thus increasing the tension of the 
drumhead. This movement of the 
malleus is communicated to the 
long process of the incus, which in 
turn acts upon the stapes and com- 
presses it into the oval window. 
Prolonged retraction of the mem- 
brana tympani is attended with a 
shortening of the tendon of the 
muscle, a condition which materi- 
ally interferes with the cure of the 
deafness resulting from these con- 
ditions. The stapedius muscle 
acts in antagonism to the tensor 
tympani, and counterbalances the 
compression of the foot plate of 
the stapes in the oval window. The 
membrana tympani, the circular 
ligament of the oval window, and 
the interposed chain of ossicles are 
thus poised to receive the sound 
waves and transmit them to the 
cochlea, where the impression is 
received by the delicately attuned 
organ of Corti, which in turn transmits the impression through the 
auditory nerve to the auditory centre of the brain, where it is perceived 
as sound. 

It is apparent from the foregoing physiological data that it is of great 
therapeutic value to maintain free drainage and ventilation of the middle 
ear and its accessory cavities, and to prevent the morbid changes incident 
to the inflammatory processes of the middle ear. 

Physiology of the Sound-perceiving Apparatus.— The sound- 
perceiving apparatus is composed of the terminal nerve filaments of 
the labyrinth, the acoustic (auditory) nerve, and the auditory centre in 
the brain. 




Coronal section through the tympanum, a, 
extremity of the upper; b, extremity of the 
lower bony wall of the meatus; d, tegmen 
tympani; e e, attic, external portion, internal 
portion; /, malleus and superior ligamentum 
mallei; 2, incus; h, stapes within the fenestra 
vestibuli; i, promontory; lc, Prussak's space; 
m, hypotympanic recess (cellar); I, scar in the 
lower half of the drumhead in apposition with 
the promontory; 2, incudostapedial junction. 
(After Bruhl-Politzer.) 







U: 



*&& 



m 



PHYSIOLOGY. OF THE EAR 613 

Auditory Nerve. — The auditory nerve arises between the facial 
and glossopharyngeal nerves in the medulla oblongata, and passes into 
the internal auditory canal, in the fundus of which it divides into two 
branches; the vestibular branch (nerve) enters the vestibule, where it 
sends twigs to the utricle and the superior ampulla? of the semicircular 
canals; the cochlear branch (nerve) passes into the cochlea and gives off 
twigs to the saccule and to the ampulla of the superior semicircular canal. 

The distribution of the auditory nerve in the cochlea forms a spiral 
ganglionic ribbon, the ganglionic cells being connected by medullated 
nerve fibers, the whole being supported on the membranous cochlea, 
which is attached to the osseous cochlea by fibrous bands. The mem- 
branous labyrinth is filled with a fluid called endolymph, and is surrounded 
by a fluid called the perilymph. The cochlear distribution of the auditory 
nerve is called the organ of Corti. 

Function of the Vestibular Apparatus. — Within the vestibule (saccule 
and utricle) the otoliths, acting upon the delicate hair-like prolongations 
within the ampulla, preside over the sense of the position of the head 
(body) in space. The angle of the impact of the otoliths upon the hair- 
like processes (the relative bending) creates a sensation which, being 
interpreted by the brain centres, gives conscious knowledge of the relative 
position of the head (body) to the line of gravity and consequently to the 
plane of the earth. In other words, they aid in the maintenance of 
equilibrium. (See Functional Tests of the Vestibular Apparatus.) 

Function of the Semicircular Canals. — These canals are the organs of 
coordinated movements, or statical sense; hence, they are also a part of 
the apparatus presiding over the sense of equilibrium. (See Functional 
Tests.) 

Function of the Cochlea. — Corti's cells constitute the true terminal 
acoustic (auditory) nerve apparatus. They are about 2000 in number, 
and are ciliated. The function of the cochlear apparatus is to perceive 
and differentiate sound waves, and convey them to the auditory nerve 
trunk, thence to the acoustic centres of the brain, where they are per- 
ceived as sound. 

Shambaugh controverts the theory of Helmholtz that the basilar mem- 
brane is the resonator of the internal ear. According to Helmholtz, 
the fibers of this membrane vibrate in sympathy with the sound waves 
as they react upon the labyrinth, and thus stimulate the hair cells of 
the organ of Corti. Shambaugh's conclusions are ingenious, and are 
as follows (Plate XVI): 

1. "The hair cells of the organ of Corti are the real end organs wherein 
the physical impulses of sound waves are transformed into the nerve 
impulses, which result in tone perception. 

2. "The perception for the various tones takes place in different parts 
of the cochlea, those of higher pitch being taken up by the hair cells 
located near the beginning of the basal coil, those of lower pitch by the 
cells near the apex of the cochlea. 

3. "The stimulation of the hair cells is effected only through the 
medium of their projecting hair. 



614 



THE EAR 



4. "The hypothesis that each hair cell acts as its own agent in selecting 
its stimulus from the impulses passing the endolymph is shown to be 
untenable for a number of reasons, chiefly, however, because the relation 
existing normally between the hair cells and membrana tectoria will 
not permit of these impulses in direct contact with the hair cells. I have 
shown conclusively that the hairs of the hair cells project normally into 
the under surface of the membrana tectoria. 



Fig. 376 



Iv 







^fr — * ■ ^" ^ ■ " — - - ■ J! ^^. VS* 



lv, labium vestibularis; mt, membrana tectoria; It, labium tympanae; nib, membrana basilaris; 
Is, ligamentum spirale; sh, streifen of Hensen. (Shambaugh. 



5. "The stimulation of the hair cells is accomplished only through 
an interaction between the hairs of the hair cells and the membrana 
tectoria. 

6. "The hypothesis of Helmholtz that this stimulation is brought about 
through the vibration of the fibers of the membrana basilaris is untenable, 
especially for the following reasons: In tracing the membrana basilaris 
toward the beginning of the basal coil in the vestibule this structure is 
found at a considerable distance from the lower end of the coil, and where 
a perfectly formed organ of Corti it still present, to become so stiff and 
rigid as to render it incapable of vibrating. Even a complete absence 



PHYSIOLOGY OF THE EAR 615 

of a basilar membrane in this locality is sometimes noted. The logical 
conclusion is that since the stimulation of the hair cells in this locality 
is accomplished without the intervention of a vibrating membrana 
basilaris, therefore the stimulation of the hair cells throughout the cochlea 
is not dependent on the vibration of this membrane. 

7. "The logical conclusion is that the stimulation of the hair cells is 
accomplished through vibrations of the membrana tectoria transmitted 
to it by impulses passing through the endolymph. 

8. "The membrana tectoria is shown to be so constituted anatomically 
as to be capable of responding to the most delicate impulses passing 
through the endolymph. Furthermore, the great variation in size of 
this membrane from one end of the cochlea to the other, together with 
its lamellar structure, suggests the probable physical basis which renders 
it capable of acting the part of resonator by responding in one part to 
impulses of a certain pitch, and in another part to impulses of another 
pitch (Fig. 376). 

9. " Finally, the pathological phenomena of 'tone islands/ 'diplakousis 
binauralis of disharmonica,' and of 'tinnitus aurium,' are all plausibly 
accounted for in this conception of the physiology of tone perception. 

10. "To restate briefly the process by which the phenomenon of tone 
perception is accomplished: The sound waves conducted from the air 
impinge upon the membrana tympani, producing vibrations in it. These 
vibrations conducted along the chain of ossicles transmit impulses 
to the intralabyrinthine fluid through the medium of the foot plate of 
the stapes. The impulses originating in the fluid in the vestibule pass 
directly into the scala vestibuli and through the membrane of Reissner 
to the endolymph, where sympathetic vibrations are imparted to the 
several parts of the membrana tectoria, depending on the pitch of the 
tone. The vibrations in turn stimulate the hairs of the hair cells which 
normally project into its under surface. The nerve impulses originating 
from all the hair cells thus stimulated by a particular tone come together 
in the brain centre in the cortex when the tone picture forms the final 
step in the process of tone perception." 



CHAPTER XXXIII 

THE FUNCTIONAL TESTS OF HEARING 1 

Physiological Facts. — (a) Range of Hearing. — The normal range of 
hearing, in man, for musical tones is from 16 to about 22,000 double 
vibrations per second. After the fiftieth year the upper limit of hear- 
ing is somewhat lowered. 

(6) Paths through Which the Sound Waves Reach the Labyrinth. — 1. 
Sound waves reach the labyrinth chiefly through the tympanic mem- 
brane, the ossicles and the oval window into which the foot plate 
of the stapes is inserted. The foot plate is attached to the oval window 
by a fibrous membrane which allows it to vibrate therein. Politzer 
demonstrated that the malleus performed the greatest excursions, 
the incus less, and the stapes least of all. The relation of the area 
multiplied by the excursion of the foot plate of the stapes to the 
similar factors of the membrana tympani was found by Bezold to be 
as 1 to 778. Example (the product of the area of foot plate of stapes 
x its movement distance) is to (the product of the area of membrana 
tympani x its movement distance) as 1 to 778. This is about the 
relation of the specific gravity of air to that of water (1 to 774). The 
mass vibrations of the lower tones in their transmission through the 
drum membrane and the chain of ossicles to the perilymph are trans- 
posed to this degree into molecular vibrations. Hence the loss of hearing 
for low tones in disease of the conduction apparatus. 

2. Sound waves also reach the labyrinth through the fenestra coch- 
leae (round window), therefore the function of the ear is not altogether 
destroyed when the foot plate is fixed, as in spongifying of the bony 
capsule of the labyrinth. 

Sound waves are also carried to the labyrinth to a considerable 
extent through the bones of the skull (Fig. 377). This explains why 
some deaf persons hear tolerably well over the telephone. Weber's 
well-known experiment demonstrates that when a tuning fork is placed 
upon the skull and the external meatus is artificially closed with the 
finger, the vibrating fork is heard much better on that side. In other 
words bone conduction is thus increased. In the normal ear, hearing 
by bone conduction for tuning forks of medium pitch is about one-third 
to one-half of that by air conduction. The relative duration of hearing 
by bone and air conduction varies greatly with different forks. It also 
varies with the point of contact made with the fork. Bone conduction is 
best over the mastoid antrum. Politzer, Bezold and x\ndrews have called 
attention to the varying results obtained by different forks of the same 
number of vibrations. Each fork should, therefore, be carefully and 

1 This section has been entirely rewritten by Dr. Alfred Lewy. 

(616) 



THE FUNCTIONAL TESTS OF HEARING 



617 



repeatedly tested upon normal persons to establish its normal register. 
By normal register is meant the length of time the fork is heard by 
normal ears by bone conduction when placed over the mastoid antrum, 
and the time it is heard by air conduction when held as near as possible 
to the auditory meatus (Fig. 382). 



Fig. 377 




Air and bone conduction (schematic): 1, cranium; 2, cerebrum; 3, auditory nerve going to tem- 
poral lobe; 4, labyrinth; 5, tympanum and ossicles; 6, auditory meatus; 7, pinna?; a, tuning fork placed 
on the vertex; a b, osteal bone conduction; a c, craniotympanal bone conduction; d, tuning fork held 
in front of the ear; d c, air conduction. (After Briihl-Politzer.) 



5. The Bezold-Edelmann set of forks and whistles has become 
standard. It is constructed upon scientific principles and should be 
used by all otologists. It covers the range of hearing of the human 
ear. The forks are weighted and free from overtones. With them 
deaf mutes may be tested for "islands of hearing," and when found 
the islands or areas of the organ of Corti which are functionating may 



618 THE EAR 

be utilized to teach speech if within the range of tones used in articulate 
speech. They are indispensable for scientific work. No other set of 
forks and whistles meets all the demands. One may usually, though 
not always do diagnostic work with three well-selected forks, for instance 
the Reiner set as used by Neumann of Vienna. This set consists of 
one C (64 d.v.) for estimating the low tones, one d# (153.8 d.v.) for 
the relative bone and air conduction, and c 4 (2048 d.v.) for estimating 
the high tones. While one may not determine the low or the high limits 
with these, a loss of hearing for low tones or for high tones may be 
determined by the shortening of the time the C or c 4 respectively 
are heard as compared with the normal. 

(c) Tension. — The tensor tympani draws inward the hammer handle 
and the drum membrane and tilts the hammer head and incus so that 
the foot plate of the stapes is pushed into the oval window, thus 
increasing the pressure on the perilymph. The stapedius by its con- 
traction tilts the anterior and broader end of the foot plate outward, 
the narrower, posterior portion of the membrane of the oval window 
acting as the fulcrum, the power being applied at the head of the 
stapes and incudostapedial joint. Thus the stapedius is the antago- 
nist of the tensor tympani. Their exact function in the process of 
hearing has not yet been satisfactorily demonstrated. 

(d) Perception. — The normal ears perceive sound in its actual pitch. 
Both ears perceive it exactly alike in pitch, timbre, and intensity. 
In certain pathological conditions one or both ears may be " out of tune," 
a condition known as diplacusis, when both ears are not in consonance. 

Principles Underlying the Tests of Hearing. — 1. The normal range 
of hearing is from 16 to 22,000 double vibrations per second, that is, 
from C 2 (16 d.v.) to about f 7 (22,097 d.v.). 

2. When the conduction apparatus is diseased or obstructed the 
hearing is impaired or lost principally for the lower tones of the scale. 

3. When the perception apparatus is diseased the hearing for all 
tones is impaired, and is entirely lost (as a rule) for the high tones. 

4. The normal ear hears the tuning fork about two or three times 
as long by air as by bone conduction. The ratio varies with different 
forks. 

5. When the conduction apparatus is diseased or obstructed, bone 
conduction is increased and air conduction is diminished; bone con- 
duction may be so much increased that the fork is heard longer by 
bone than by air conduction (Negative Rinne). 

6. When the perception apparatus is diseased bone conduction is 
diminished. Hearing for the tuning fork by air conduction is dimin- 
ished to a less degree, so that it appears relatively exaggerated. 

The Functional Tests of the Auditory Apparatus. — In considering the 
physiological tests of the functional ability of the cochlea it is to be 
remembered that no one of the tests described is alone sufficient for 
an accurate diagnosis, as a rule. Each test has its value as a part 
of the examination and in corroboration of the other tests, and the 
diagnosis is made from the entire picture. While it is not always 



THE FUNCTIONAL TESTS OF HEARING 619 

necessary to go through all the tests as described in the schema below, 
it is the' opinion of the writer that a diagnosis made without at least 
the more fundamental ones is merely a guess. As will be seen by a 
careful study of the preceding paragraph the fundamental principle 
is the bone conduction. Markedly diminished bone conduction nearly 
always means disturbance or disease of the perception apparatus. 
Markedly prolonged bone conduction means disturbance or disease of 
the conducting apparatus. The other tests and the physical examina- 
tion, both local and general, are necessary to give more detailed infor- 
mation upon which intelligent treatment and prognosis may be based. 
The otologist should make constant use of the tests, in order that he 
may become skilled in their application and in his deductions therefrom. 
It is necessary, therefore, to make a routine practice of applying them 
to all or nearfy all cases coming under observation. This is the practice 
of the author in both private and clinical work and he feels well rewarded 
for his trouble. The portion of the Politzer clinic examination schema 
referring to the functional tests is as follows: 

Right Left 

Whisper 

Conversation 

Acoumeter 

Weber test 

Schwabach test 

Rinne test 

Low limit 

High limit 

Whisper, conversation or acumeter after inflation. 
The Voice Test. — The practical test of hearing is the ability to hear 
conversation, but as the spoken voice is usually too loud for the distance 
obtainable in an ordinary office, and as there is a great difference in 
the carrying quality of different consonants and vowels, the whispered 
voice is more applicable, provided the deafness is not of such degree 
that the whisper is heard with great difficulty or not at all. In using 
the whisper it should be given with only the residual air, so as to obtain 
the greatest degree of uniformity, and the surgeon should train his 
voice to this end. In a perfectly quiet hall the whisper may be heard 
by a normal ear at about 40 meters. In 1871 Oscar Wolf published his 
conclusions as to the voice as a means of testing the organ of hearing. 
He found the letter R the lowest in the scale, while the highest number 
of vibrations were produced by the letter S. In the same manner 
some words are high pitched while others are low. Examples of high- 
pitched words are : six, seize, tease, message, shady ; low-pitched words : 
horror, rural, moon, rude; medium-pitched words : table, Mary, baby. 
To a certain degree the voice test may indicate the form of deafness, 
as, for instance, in conduction deafness the high-pitched words are 
heard much better than the low ones, as a rule. The reverse is not 
true to any degree in nerve deafness; however, in this condition Wolf 



620 



THE EAR 



states that F sounds are not heard. It should be remembered that in 
pathological conditions of the hearing that neither the whisper nor 
any other test is a correct indication of the hearing for conversational 
voice, and that some voices are heard better than others. It is a 
common experience for people with a pure conduction deafness to 
find that they hear high-pitched feminine and children's voices better 
than they do a low masculine one. 

Technic. — (a) Place the patient at one end of a quiet room with the 
ear to be tested toward the examiner's end of the room. The patient 
should not see the lips of the physician during the test. Some deaf 
people become very expert in lip reading. 

(b) Have the patient moisten the tip of his index finger and insert 
it firmly into the meatus of the ear which is not being tested. The 
physician should himself see that this is properly done. 

(c) The physician begins the test from without the range of the 
patient's hearing, approaching quietly until patient repeats correctly 
what is spoken or whispered to him, and the distance so found is 
entered on the record. If the room is not long enough the physician 
should turn his back to the patient. If the distance is still too short 
the patient should turn his open ear to the opposite wall. Each of 
these maneuvers is supposed to indicate an increased distance of about 
one-third. The spoken or the whispered voice is used according to 
the degree of deafness, and the record should state which style of 

speech is used. Repeat test with 
F 10 - 378 the other ear, using different words 

Tor numbers. 
(d) Inflate the ears. 
(e) Repeat the tests and record 
the difference, if any, following 
inflation. 

The Politzer Acoumeter. — (Fig. 
378) . This instrument was designed 
to give an accurate mechanical 
standard of measurement for the 
hearing distance. All the instru- 
ments are supposed to be of the 
same pitch and timbre, and the 
hearing distance for them in a quiet room should be about 40 feet. 
Politzer and Lucae claim that this instrument more nearly corresponds 
with the voice tests than either the watch or the distance test with 
the tuning fork. 

The Watch Test. — This instrument has long been used to test the 
acuteness of hearing. As a diagnostic aid it is far inferior to other 
tests, but is mentioned because of its common use. It may be used 
to measure the hearing distance (a) by approaching the ear with it; 

(b) by firm contact with the auricle if not heard by air conduction; 

(c) by contact with the mastoid process; (d) by placing it between 
the teeth and noting in which ear it can be heard most plainly, as in 




Politzer's acoumeter. 



THE FUNCTIONAL TESTS OF HEARING 



621 



the Weber experiment; (e) for comparison from time to time during 
treatment. Its drawbacks are: Watch-ticks are not standardized; 
the hearing for the watch is no indication whatever of the hearing 
for conversation; the patient becomes accustomed to the sound of 
one watch and apparently hears it better when there is no real improve- 
ment in hearing; the patient gets the habit of using his own watch 



Fig. 379 



I^GKS 




Fig. 380 



tora 




The Weber experiment. The patient is 
deaf in the left ear and the sound lateralizes 
to the left ear, thus indicating disease of 
the sound-conduction (middle ear) apparatus 
to the left ear. 



The Weber experiment. The patient is 
deal in the left ear and the sound lateralizes 
to the right or good ear, thus indicating disease 
of the perception apparatus (labyrinth) of the 
left ear. 



frequently, and in incurable deafness his condition may be much 
the same as that of the neurasthenic entrusted with a clinical ther- 
mometer. 

The Weber Test. — E. H. Weber first found that a normally vibrating 
tuning fork (Fig. 379) placed upon the skull is much more distinctly 
heard in that ear the external meatus of which is closed by the finger. 
In other words, the sound is referred to that ear in which a conduction 



622 THE EAR 

deafness has been produced. Clinically it has been shown that when 
the middle ear alone (including the Eustachian tube) is diseased, or 
when the external canal is obstructed, the sound of the vibrating 
tuning fork when on the median line of the skull, as the vertex, fore- 
head, teeth or chin, is lateralized toward the affected ear; and that when 
the internal ear alone is affected the sound is lateralized toward the 
unaffected ear. This test is not altogether dependable in bilateral 
deafness nor in unilateral deafness when both the middle and internal 
ear are affected, as here are two opposing conditions, one tending to 
increase while the other tends to decrease bone conduction. Often, 
also, patients do not lateralize the sound, or are inaccurate. Hence 
this test should be accepted only in corroboration of the other tests; 
if inconsistent with them it should be ignored. In suppurative disease 
of the ear if the sound is first referred to the sick ear but subsequently 
changes and is referred to the well ear, it is very suggestive of involve- 
ment of the labyrinth. 

Technic. — The Bezold large A fork (108.7 d.v.), or any fork between 
this and c 2 may be used (Dr. Alfred Lewy thinks c 2 is rather high, 
but it is used by many others). The vibrating fork is placed in the 
median line on either the vertex, forehead, glabella, teeth, or chin, 
and the patient asked to indicate in which ear the sound appears to 
be loudest. This is entered on the record. Patients often have the 
preconceived notion that they must hear it louder in the better hearing 
ear. This should be overcome. In order to test the accuracy of the 
answer the following simple procedure will often suffice: If the 
patient says, "I hear it louder in my right ear," the surgeon closes the 
right ear with his finger (the fork meanwhile remaining in place and 
vibrating) and asks, "Now where do you hear it?" If the patient then 
imagines the sound is referred to the open ear he may be known as 
inaccurate. 

The Schwabach Test. — Schwabach first noticed that the sound of 
the tuning fork through the cranial bones in conduction deafness 
was heard longer than normal. The explanation of this is still open 
for discussion. It is at -least partially due to the interference with 
the entrance of adventitious sounds from without, and with corres- 
ponding interference with the egress of some of those received through 
the cranial bones. The practical application of this is the bone con- 
duction for the tuning fork as compared with the known normal for 
that fork. This test is very valuable in connection with the relative 
air and bone conduction test (Rinne test). Markedly prolonged 
bone conduction indicates a conduction deafness. Markedly shortened 
bone conduction indicates an internal ear lesion or disturbance, i. e., 
nerve deafness. That this is not necessarily an organic lesion is shown 
by cases described by Alfred Lewy (Laryngoscope, March, 1913). 
Sometimes when the patient ceases to hear the fork by bone conduction, 
if the fork is removed for a few seconds and then replaced without 
having been struck again the patient again hears it. This is known 
as the "fatigue symptom," and is supposed to be due to fatigue or 



THE FUNCTIONAL TESTS OF HEARING 623 

exhaustion of the nerve, and to occur in neurasthenia and hysteria. 
In combined cases, i. e., cases of mixed conduction and perception 
deafness, the Schwabach test may show the bone conduction somewhat 
shortened, slightly lengthened, or approximately normal. On account 
of the affection of the perception apparatus the disturbance of the 
conduction apparatus fails to bring about the usual increase in bone 
conduction. 

Technic. — The fork for this purpose should be free from overtones, 
not so low that the vibrations are transmitted as concussions to the 
skull nor so high that it is difficult to distinguish between the air and 
bone conduction. The best fork is the Edelmann-Bezold A (108.7 
d.v.) as recommended for the Weber test. Any good fork of sufficient 
intensity and duration, free from overtones, between A and c 2 may 
be used, but the Reiner d# (153.8 d.v. with clamps) is next choice. 
The normal register of the fork must have been ascertained previously 
by trials on normal persons. In order to reproduce even results the 
fork must always be struck on the same object, in the same manner 
and with the same force, and applied to the skull of the patient with 
the same degree of pressure. For instance, in using the Bezold A, the 
fork may be dropped from the vertical to the horizontal by its own 
weight, striking on the examiner's knee (the examiner's thigh is flexed 
to a right angle with his body and the handle of the fork just touches 
the thigh at the beginning of the fall), the fork is then rested by its 
own weight, on the patient's skull. Or one may use a small rubber 
hammer made for the purpose of striking the tuning fork, or the rubber 
hammer used by neurologists for obtaining tendon reflexes will do. 
The number of seconds from the stroke till the patient no longer hears 
the fork is noted, preferably on a stop watch, and entered on the record 
"Schwabach — seconds." (If preferred one may record the per cent, 
of normal, e. g., S. 40 per cent, or 150 per cent.) The patient must 
be instructed to raise his hand or otherwise indicate the moment 
he no longer hears (not feels) the fork. 

The Rhine Test (Combined Testing of Bone and Air Conduction). — 
This is a very valuable test. If one holds the handle end of a vibrating 
tuning fork against the mastoid process until the tone is no longer 
heard, and then brings the prongs near the external auditory meatus 
(Fig. 379 and 380), the sound will again be heard, the length of time 
the tone is heard through the air being double or treble, according 
to the fork used, the hearing time through the bone. This is the 
"Positive Rinne." It occurs normally. It also occurs in nerve deaf- 
ness, though in this condition both the bone and air conduction are 
shortened — "Shortened Positive Rinne." In a pure conduction 
deafness the bone conduction is relatively lengthened while the air 
conduction is relatively shortened. When this condition advances to 
a point where bone conduction exceeds air conduction we have a 
"Negative Rinne." Negative Rinne, but with both bone and air 
conduction very much shortened, may also occur in severe nerve 
deafness. Plus-minus Rinne is a term applied when bone and air con- 



624 



THE EAR 



duction are equal. Indefinite Rinne, when air conduction is entirely 
absent. False Rinne, when one ear is totally deaf and the fork appar- 
ently heard on the mastoid of the deaf ear is really heard in the 
other ear. The bone conduction as found with the Rinne test should 
corroborate the Schwabach test. Occasionally bone conduction is pro- 
longed for the A fork, and shortened for the a 1 . This condition has 
been found in syphilis by Norval Pierce and Alfred Lewy in a few 
cases. 



Fig. 381 



Fig. 382 




Showing the Rinne a' fork in position on the 
mastoid process in the Rinne test. 



Showing the Rinne a' fork held close to 
the ear in Rinne's test; indeed, the prong 
tips should be within the concha. 



Technic. — The best fork for this purpose is the Edelmann a 1 (435 
d.v.). It is free from overtones and of sufficient intensity and duration, 
and yet the tone is not carried through air conduction to the opposite 
ear from the one being tested, c (128 d.v.), d# (153.8 d.v.), c 1 and c 2 
may also be used if they fulfil the above indications. V. Mueller & Co., 
have recently devised a c 2 fork that appears practicable. The fork 
for this test should be carefully selected, as it is the most frequently 
useful one. The same degree of force and the same object (non-metal) 
for striking should always be used. Striking the fork on the knee-cap 
does very well. It is then firmly placed with the end of the handle on 
the mastoid process over the antrum, being held by the handle near 
the prongs. Care should be observed to use uniform pressure and to 
avoid contact with the auricle or hair; when the patient indicates that 
the sound is no longer heard, the fork is held suspended with the 
prongs flatwise toward and as near as possible to the concha without 
touching. In this position the sound is heard the best and longest. If 
abundant hair prevents the fork being held in this manner it may be 
held prongs up. If the Schwabach test shows greatly increased bone 
conduction it often saves time to get the air conduction first in making 
the Rinne test, as it will probably be a "negative." The length of 



THE FUNCTIONAL TESTS OF HEARING 625 

time the fork is heard by bone conduction and by air conduction is 
measured in seconds, preferably with a stop watch, from the time the 
fork is struck, one stroke sufficing for both parts of the test, and is 
entered on the record "Rinne +12:35" or "Rinne -20:15" for 
example; the bone conduction first; or if written as a fraction (-g-f) the 
bone conduction is the numerator. The normal register for the fork 
used must be known. 

The Low Limit. — Normally the low limit is about C2 (16 d.v.), but 
some persons with otherwise normal hearing fail to distinguish this 
tone. However, failure to hear G 2 (24 d.v.) may be safely put down 
as indicating some loss of hearing for lower tones. Bezold states that 
failure to hear Ci (32 d.v.) in conduction deafness indicates ankylosis 
of the stapes. Loss of hearing for low tones practically always occurs 
to some degree in conduction deafness; the greater the loss the greater 
the probability of stapes ankylosis. It rarely ocurs in pure nerve deaf- 
ness (except congenital), but of course occurs in combined cases. 
The mass vibrations of the lower tones are transposed by the system 
of levers comprising the membrana tympani and chain of ossicles into 
molecular vibrations, in which form they are transmitted to the peri- 
lymph. Anything interfering with the function of the conducting 
apparatus hinders the transmission of low tones. 

Technic. — The examiner begins with the lowest fork; if this is not 
heard the next one higher is used, first before one ear than the other, 
until the patient, whose eyes should be closed during the procedure, 
indicates that he hears the tone. The lowest fork heard by each ear 
is entered on the record. If one uses but one fork for estimating the 
hearing for low tones C (64 d.v.) is a practicable one. It must be 
weighted to prevent overtones, and its normal register must be known. 
One can then enter on the record the fraction or percentage of time 
as compared with the normal that this fork is heard. Shortening of 
the hearing time indicates loss of hearing for low tones. 

The High Limit. — Edelmann states that the educated ear can dis- 
tinguish f 7 (22,097 d.v.) on a good Galton whistje (Fig. 381), and 
d 7 (18,581 d.v.) on a Schulze monochord. The writer also found 
d 7 the limit on the Struycken-Schaefer monochord, but many normal 
ears do not hear beyond c 7 (16,554 d.v.). After the age of about 50 
years the high limit declines, owing to senile changes. According to 
Zwaardemaker at the beginning of senility the limit is about a 6 ; 
in old age about g 6 . These data should be borne in mind in estimating 
the significance of tests for the range of hearing. Any marked loss 
of the upper range indicates some pathological process in the internal 
ear. When associated with a conduction deafness it indicates the 
probability of beginning degeneration in the basal turn of the cochlea. 
A moderate loss for high tones occurs quite commonly in spongifica- 
tion of the labyrinthine capsule. The writer is of the opinion that 
any marked loss of the upper tone limit is of unfavorable prognostic 
import when it occurs in any form of deafness except hysterical and 
in acute suppurative otitis media. 
40 



626 



THE EAR 



Technic—(a) The Galton whistle (Edelmann's) (Fig. 383). This 
whistle has an adjustable aperture and graduated pipe-length, both 
operated by screws, and is blown by compression of a bulb. A scale 
for translating the tones into their proper musical designation accom- 
panies each instrument. The whistle must be blown gently as it is 
difficult to exclude the opposite ear even when the meatus is occluded. 



Fig. 383 





Testing the hearing with the Galton-Edelmann whistle at eighteen inches. 

Begin above the high limit and gradually lengthen the pipe by the 
screw until the sound is heard as a clear whistle (as distinguished from 
the blowing sound) . The number of the line and the aperture distance, 
or its equivalent in musical terms is entered on the record. The small 
whistles of American make are practically useless except in cases 
with very marked loss of upper tone limit. All whistles of course 
test only air conduction. 

Fig. 384 




Monochord. 



(b) The Monochord (Fig. 384). — This instrument consists of a 
metal frame on which is stretched a piano wire. On the frame and 
wire is fitted a block, which by its position regulates the pitch. A 
bone button can be attached to one end of the frame, which is held in 
contact with the mastoid process to test bone conduction for high 



THE FUNCTIONAL TESTS OF HEARING 627 

tones, an advantage which this instrument has over the whistle. 
Transverse vibrations are caused by striking the wire with a small 
hammer or drawing a violin bow across it. For the highest tones 
longitudinal vibrations are used, and these are obtained by rubbing 
the wire lengthwise with a felt pad moistened with turpentine and 
benzole, or carbon tetrachloride. (A felt-tipped bottle which keeps 
automatically moist is furnished with the instrument.) The range 
of the Struycken-Schaefer monochord is from g 1 to above the high 
limit. The frame is calibrated so that the pitch can be read directly 
for longitudinal vibrations, and in centimeters for the transverse 
vibrations, which requires reference to a scale for translation into 
musical terms. In obtaining the transverse vibrations (low tones), 
the instrument must be rested on a table to act as resonator, as other- 
wise the tone is too thin. In obtaining the high tones the patient 
must distinguish between the rubbing and the clear tone, but this is 
not difficult. The directions for use which accompany this instrument 
as well as the Galton whistle must be carefully studied. 

(c) The c 4 (2048 d.v.) fork. — By using the large size c 4 fork of 
either the Bezold, Hartmann, or the Reiner set, one may test the high 
limit quite satisfactorily and more simply than above described. The 
fork is stroked gently, tapped with the finger or struck on metal 
according to the degree of loss for the upper tones, or the examiner 
can by alternately holding the vibrating fork before the patient's 
and his own ear (if normal) determine if the upper limit is normal, 
slightly short, moderately short or very much short, and so enter it 
on the record. The small size c 4 forks seldom vibrate long enough 
to perform this test satisfactorily. 

Unilateral Total Deafness. — If both ears are occluded by the moist- 
ened fingers a loud fork or voice can still be heard. It is evident that 
though one ear be totally deaf the other cannot be entirely excluded 
from hearing by simple occlusion of the meatus, therefore it is necessary 
to use one of several methods that have been devised, all of which 
operate both by occluding and producing noise in the ear which it is 
desired to put out of commission temporarily, while the supposedly 
totally deaf ear is tested. When one of these devices is properly applied 
to one ear, if the other is totally deaf the patient will not hear even a 
loud voice (unless shouted directly toward the head). 

The Neumann Noise Apparatus. — This is an electrical device 
which operates with either a direct or an alternating current. It 
consists of a rheostat, and interrupter and two telephones, fitted 
with ear-pieces, which fit snugly into the external meati. A switch 
causes the noise to be heard in either or both ears at the will of the 
operator. The rheostat controls the intensity of the noise. The 
instrument can also be used to discover malingerers who claim unilateral 
deafness. 

The Barany Noise Apparatus (Fig. 385). — This is a clockwork buzzer, 
which when wound up is operated by pressing a button while the ear- 
piece is in place, 



628 



THE EAR 



The Pierce Method. — A C fork (64 d.v.) of sufficient loudness and 
duration (the one recommended for the low limit or a Koenig C fork 
will do) is fitted on the handle end with a conical ear-piece, which is 
moistened, and while the fork is vibrating loudly placed firmly in the 
external meatus. 

Other methods are the running of a stream of water or air under 
slight pressure into the canal of the ear to be excluded. 

The Gelle Test. — If the air is compressed in the external canal of 
the normal ear (using an air bag with a snug fitting ear-piece), the 
tone of a vibrating tuning fork placed on the vertex or mastoid will 
be perceived greatly diminished. According to Gelle if the stapes is 
ankylosed the pressure in the external canal cannot be transmitted 
to the labyrinthine fluid and the test is then negative. A more prac- 
ticable method of performing this test, as devised by Barany, is as 
follows: A branched or "T"-shaped auscultation tube is used; two ends 
carry snug-fitting ear-pieces, the third a mouth-piece. One of the ear- 
pieces is held tightly by the patient in his external meatus, so that no 
air escapes; the other likewise by the examining physician; the third is 
used to compress the air in the tube and in the external canals by the 

physician blowing into it. The stem of the 
Fig. 385 vibrating tuning fork is placed about the 

middle of the rubber tubing. If the stapes 
is not ankylosed, both the patient and 
the physician will hear the sound greatly 
diminished during compression of the air 
in the tube (unless the hearing is already 
very poor) . Thus the examiner has a control 
test. 

Bing Test.— No. 1.— The small end of a 

speaking trumpet is fitted into the free 

end of a catheter, which is inserted into the 

Eustachian tube so that the sound waves 

enter the cavum tympani and come into 

direct contact with the foot plate of the 

stapes and the membrane of the round 

window. If the speech is heard decidedly 

better in this way than with the end of the 

speaking trumpet in the external meatus, the inference is that the 

interference with conduction is outside the stapes, that is, in the 

incus, malleus, or drum membrane. 

No. 2. — Bing claims that after the tone of a vibrating tuning fork 
on the vertex becomes inaudible it is again heard if the meatus is 
occluded with the finger, if there is a labyrinthine affection. As this 
occurs normally, the test is useful only in severe deafness. If there is 
a conduction deafness the sound is not again heard when the meatus 
is occluded. 

The various forms of deafness are described in detail under their 
respective headings. 




Barany's noise apparatus. 



THE FUNCTIONAL TESTS OF HEARING 629 

The Function Tests of the Vestibular Apparatus.— The whole ques- 
tion of the labyrinth will be considered together, as there must be such 
a constant reference, back and forth, to the theoretical and practical 
problems that the student will find it expedient to have all the data 
grouped. (See Chapters XLIX and LI, The Labyrinth: Us Physiology, 
Functional Tests, Pathology, and Disease.) 



CHAPTEE XXXIV 

GENERAL ETIOLOGY OF DEFECTIVE HEARING 

Defects of hearing may arise from any condition that affects the 
functional integrity of the conduction or the perception apparatus of the 
organ of hearing. It may be stated, as a general law, that the deeper 
(nearer the acoustic centre) the lesion, the more profound is the dis- 
turbance of hearing. 

A. Defects of Hearing Due to Lesions of the Auricle. — This divi- 
sion of the subject may be passed by without analysis, as there is but 
slight impairment of hearing, even from the total loss of the auricle. 

B. Defects of Hearing Due to Affections of the External Meatus. 
— (a) Inspissated cerumen, (b) Furunculosis. (c) Dermatitis, (d) 
Eczema, (e) Foreign bodies, animate and inanimate. (J) Exostosis 
of the meatus, (g) Collapse of the cartilaginous meatus. (K) Con- 
genital artresia of the meatus, (z) Congenital absence of the meatus. 
(f) Cholesteatoma. 

A glance at the foregoing analysis makes it apparent that hearing is 
diminished on account of the obstruction to the transmission of sound 
waves through the external auditory meatus and by the congenital 
absence of this canal. Congenital absence of the external auditory 
meatus is nearly always attended with absence of the middle and the 
internal ears, hence the deafness may be attributed more to the latter 
than to the former. 

Cholesteatoma within the meatus is usually coincident with the same 
process in the middle ear and the pneumatic cells of the mastoid, hence 
the defect of hearing is largely due to the condition of the middle-ear 
and the mastoid spaces. 

With these exceptions, the obstructions in the meatus account for 
deafness. It should be said, however, that inspissated cerumen in the 
meatus is often a sign of middle-ear catarrh, and the deafness may be 
partially due to this condition. 

Collapse of. the cartilaginous meatus is usually found only in the 
aged. The deafness in such cases may be due in part to senile changes 
in the middle ear and labyrinth. 

C. Defects of Hearing Due to Affections of the Drumhead. — (a) 
Perforation, (b) Thickening, (c) Calcareous deposits, (d) Cicatricial 
tissue, (e) Cicatricial bands extending to the ossicles and the wall of 
the middle ear. (/) Retraction, (g) Bulging or pouching. Qi) Inflam- 
mation (myringitis). (?) Herpes. (J) Traumatic rupture, (k) Frac- 
ture of the handle of the malleus. (/) Atrophy (lack of normal tension). 

(630) 



GENERAL ETIOLOGY OF DEFECTIVE HEARING 631 

It may be stated as a general acoustic law that anything which dis- 
turbs the normal tension existing between the drumhead, the ossicles, 
and the labyrinthine fluid will result in an impairment of hearing. It 
should be noted that in nearly all of the foregoing conditions the normal 
tension is disturbed, hence the deafness. 

In a number of lesions of the drumhead there are, of necessity, patho- 
logical changes in the middle ear which in part account for the deafness. 
For example, perforation of the drumhead is nearly always attended 
with either chronic suppuration or cholesteatoma of the middle ear, and 
possibly of the attic, the antrum, and the mastoid cells. In thickening, 
scars, cicatricial bands, calcareous deposits, retraction, and atrophy, 
middle-ear disease, usually of a chronic inflammatory nature, is present, 
and in a large measure accounts for the defective hearing. In simple 
myringitis, herpes, traumatic rupture, and fracture of the handle of the 
malleus, the middle ear may not be involved and the deafness is transitory. 

D. Defects of Hearing Due to Affections of the Middle Ear.— (a) 
Simple catarrhal otitis media, (b) Catarrh with adhesions, (c) Sclerosis 
of the mucous membrane, (d) Cholesteatoma, (e) Acute suppuration. 
(f) Chronic suppuration, (g) Ankylosis of the ossicles, (h) Ankylosis 
of the foot plate of the stapes to the oval window (fenestra of the vesti- 
bule), (i) Adhesive bands uniting the ossicles to each other, to the 
walls of the tympanum, and to the drumhead, (/') Atrophic otitis media. 
(k) Anemia of the mucosa occurring with general anemia and debility. 
(/) Loss of tonicity of the stapedius and the tensor tympani muscles. 
(m) Congenital defect or absence of the middle ear. (n) Granulations 
in the middle ear. (o) Serous and mucous accumulations, (p) Caries 
of the ossicles, (q) Caries of the walls of the tympanum, (r) Polypus. 
(s) Otosclerosis or spongifying of the bony capsule around the oval 
window. 

In the foregoing conditions we find the more common causes of deaf- 
ness. The acoustic law given in the preceding section (C), namely, that 
the condition which disturbs the normal tension between the drumhead, 
the ossicles, and the labyrinthine fluid will cause deafness, applies with 
special force to the affections mentioned in this section. All or nearly all 
the pathological lesions named materially interfere with this tension, and 
thereby interfere with the transmission of the sound waves to the laby- 
rinth. A study of these lesions will verify the general law enunciated 
at the beginning of this chapter, that as a general thing the deeper the 
lesion the more profound the deafness. For instance, a lesion affecting 
only the drumhead does not produce as profound deafness as does 
ankylosis of the foot plate of the stapes. 

Sclerosis of the mucosa of the middle ear is often complicated with the 
same process in the bone beneath it. Chronic suppuration of the middle 
ear is also often attended with sclerosis (eburnation) of the bone. 

This process may extend to the mastoid or to the bony capsule of the 
labyrinth, and thus augment the deafness. 

The author has often seen cases in which the hearing was improved 
only after the administration of iron and arsenic. These patients were 



632 . THE EAR 

anemic and suffered from general debility of a chronic type. Whether 
the improvement was due to an increased tone of the stapedius and the 
tensor tympani muscles, or to an increased tone and vital energy of the 
whole organ of hearing, would be difficult to determine. T. M. Rumbold 
believed that the trouble was in the muscles. This may be true, as there 
may be a lack of muscular tonicity here as well as elsewhere in the body. 
It may be said with equal certainty that all the tissues of the body, 
including those of all parts of the auditory apparatus, are lowered in tone 
and vital energy. We therefore think that the deafness due to or existing 
with general anemia, accompanied by seeming loss of muscular tone of 
the tension muscles of the middle ear, is probably due to a lowered 
vitality of all the parts concerned in audition. 

Granulations and polypi in the middle ear not only interfere with the 
transmission of sound waves through the middle ear, but they often 
also obstruct the external meatus. They usually signify necrosis of the 
bony walls of the tympanum and an involvement of either the cranial 
cavity, the mastoid cells, the sigmoid sinus, the jugular vein, or the 
labyrinth. 

Ankylosis of the foot plate of the stapes is a serious condition, inas- 
much as it is usually impossible to permanently overcome it. The deaf- 
ness and tinnitus are great and exert a depressing influence upon the 
patient. Great care should be exercised by the otologist in giving the 
prognosis in this class of cases. He should not hold out false hope of 
ultimate recovery, but he should so couch his language that the patient 
will not entirely abandon hope. It is the physician's office to cheer as 
well as to treat his patients. This is doubly true in hopeless cases, as 
they are often despondent to the point of suicidal mania. "Fixed atten- 
tion arouses the benumbed organs, and even though a course of office 
treatment is not advisable, the patient should be told to observe under 
what conditions he hears most clearly and to seek to adapt himself 
to his environment. Expectant attention is thus aroused, and the use- 
fulness of the auditory apparatus is maintained at as high efficiency as 
is possible. In addition to the above, rest is beneficial and the organic 
salts of iron should be administered. 

E. Defects of Hearing Due to Affections of the Eustachian Tube. 
— (a) Catarrh. (6) Fibrous thickening of the mucosa, (c) Fibrous 
bands across the lumen of the tube, (d) Fibrous rings or stricture of 
the tube, (e) Lymphoid hypertrophy within the tube. (/) Hypertrophy 
of the mucosa, (g) General sclerosis of the mucosa, (h) Paralysis of 
the palatine muscles which regulate the patency of the mouth of the tube. 

The chief function of the Eustachian tube being to maintain the 
equilibrium of air pressure between the air in the middle ear and that 
external to it, an obstruction to the normal passage of air destroys the 
equilibrium. The normal tension of the drumhead, the ossicles, and 
the labyrinthine fluid is disturbed, and deafness and tinnitus result. 

It is not usually recognized that lymphoid hypertrophy plays a promi- 
nent part in Eustachian obstruction. This must be true, however, as 
there is a considerable quantity of such tissue in the mucosa of the tube, 



GENERAL ETIOLOGY OF DEFECTIVE HEARING 633 

especially near its pharyngeal end. The same pathological processes which 
cause hypertrophy of the pharyngeal and the faucial tonsils will also 
cause hypertrophy of the tubal lymphoid tissue. We may, then, speak 
of a tubal or "Eustachian tonsil" as a cause of Eustachian obstruction. 

In long-continued catarrhal or suppurative inflammation of the middle 
ear, fibrous thickening or fibrous bands may form in the Eustachian 
tube and give rise to persistent deafness and tinnitus unless relieved by 
suitable treatment. If air is not admitted to the middle ear in sufficient 
quantity, the drumhead becomes retracted on account of rarefaction 
of the air within the middle ear, the handle of the malleus is drawn 
inward and rotated on its axis, and the chain of ossicles is forced inward 
and compresses the labyrinthine fluids. Perhaps a more correct state- 
ment would be to say that the normal tension between the drumhead 
and the labyrinth is lost, and deafness and tinnitus result. 

Tubal catarrh (salpingitis) is much more common than is generally 
supposed, and no doubt many of the so-called cases of middle-ear catarrh 
are in reality of this type. 

Since the normal patency of the tubes is controlled by the palatine 
muscles, any condition which affects their innervation or motility will 
cause defective hearing. These conditions will be considered in the 
next section. 

F. Defects of Hearing Due to Affections of the Epipharynx and 
the Fauces. — (a) Adenoids, (b) Epipharyngeal catarrh, (c) Polypi 
or other neoplasms, (d) Disease of the faucial tonsils, (e) Adhesions 
of the anterior and the posterior pillars of the fauces to the tonsils. (J) 
Suppurative inflammation of the epipharynx. (g) Paralysis of the 
palatine muscles (e. g., postdiphtheritic), (h) Infections occurring 
during the course of exanthematous fevers. 

In this category are conditions which are sources of diseases of the ear 
which are attended with impairment of hearing. All inflammatory con- 
ditions which involve the mucosa about the pharyngeal orifices of the 
tubes sooner or later extend within their lumens and cause more or less 
obstruction. If the inflammation is of a suppurative type, the germs enter 
the tube and the middle ear, and may cause an acute suppurative otitis 
media. This may become chronic, and permanent damage to the entire 
middle-ear apparatus result. 

Postnasal adenoids are recognized as frequent antecedents of tubal 
and middle-ear catarrh and deafness. 

There has been much discussion as to whether adenoids extended over 
the mouths of the Eustachian tubes. The free extremities of the lateral 
adenoid masses do, no doubt, often occlude them. Perhaps a more 
important pathological factor is that postnasal adenoids are usually 
attended with severe postnasal catarrh, which in many cases becomes 
purulent in character. This often causes obstruction of the tubes and 
thus gives rise to disturbances of hearing as well as to structural changes 
in the middle ear and its appendages. 

The etiological relationship existing between hypertrophy of the faucial 
tonsils and disease of the Eustachian tube and the middle ear has long 



634 THE EAR 

been recognized, although not as fully as it should be. Their relationship 
cannot be considered apart from that of the postnasal space, however, 
as the same conditions which affect one affect the other also. Thus the 
presence of enlarged faucial tonsils is usually attended with adenoids. 
Both being lymphoid tissue, they respond to the same irritation and 
enlarge simultaneously. Notwithstanding this fact, there are some con- 
ditions of the faucial tonsils which cause tubal obstruction independently 
of any effects due to the adenoids (C. R. Holmes). 

The presence of diseased or enlarged tonsils produces chronic hyper- 
emia of the mucosa of the epipharynx, and oftentimes a chronic catarrhal 
or suppurative inflammation is present. Enlarged and diseased tonsils 
do not always stand out beyond the pillars of the fauces. A normal 
tonsil can neither be seen nor felt. Many of the pathological tonsils are 
flat and lie hidden behind the anterior pillar. Pynchon has called them 
"submerged tonsils." He has also suggested that if they are examined 
"on the gag," they will bulge forward and inward and come into full 
view. When thus examined they appear broad and flat, with an irregular 
surface. In some cases the lacuna? are filled with debris, epithelium, 
bacteria, and pus, while in others no such accumulations are to be seen. 
This does not prove that they are not present in the pockets or lacunse, 
as upon introducing a tonsil hook into them, yellowish, round masses 
may be removed. In others the masses are encysted, probably from 
inflammatory closure of the mouths of the crypts. The point I wish to 
make is that even though the tonsils do not project beyond the pillars 
and are not apparently much diseased, they may be the seat of foci 
of infection, irritation, and septic material, which gives rise to chronic 
catarrh of the epipharynx and the Eustachian tubes. The material 
in the lacunae affords a good medium for the growth of bacteria, the 
toxins of which enter the lymphatic and the blood-vascular systems 
and cause disturbances in remote parts of the body. 

G. Defects of Hearing Due to Mastoid Affections. — As these 
conditions are secondary to and associated with pathological changes 
within the middle ear, they will not be discussed here. 

H. Defects of Hearing Due to Labyrinthine Affections. — Defects 
of hearing due to labyrinth affections vary from slight to total deaf- 
ness. The labyrinth affections causing deafness are: (a) The infec- 
tious inflammatory processes, such as acute diffuse suppurative laby- 
rinthitis, circumscribed labyrinthitis, and diffuse serous labyrinthitis; 

(b) fracture through the petrous portion of the temporal bone; 

(c) hemorrhage in the labyrinth (Meniere's disease); (d) atrophic 
degeneration of the cochlear nerve endings as in adhesive process of 
the middle ear; (e) atrophic changes in the labyrinth as in boilermaker's 
deafness; (/) syphilis and tuberculous disease of the labyrinth; (g) 
change due to drugs, such as quinine, narcotics, alcohol, etc., and 
(h) otosclerosis affecting the cochlea. 



CHAPTEK XXXV 

FOREIGN BODIES IN THE EAR. CERUMINOUS PLUGS IN 

THE MEATUS 

Children often introduce foreign bodies into the ear for very different 
reasons from those which may be ascribed to adults. For example, 
children in their play and in the spirit of imitation will do what they 
conceive is being done by others. Their elders, in order to excite wonder- 
ment and admiration, will do sleight-of-hand performances, pretending 
to remove a knife or other object from the nose, mouth, or ears. Children 
are thus led to introduce various objects into their ears. Peas, beans, 
beads, gravel, buttons, bits of sealing wax, chewing gum, cherry pits, 
etc., are commonly found in the ears of children. Burnet relates a 
case of a woman from whom a bead was removed that had been intro- 
duced sixty years previously. Children are fond of the sensation of a 
smooth body, as a bead or bean, rubbed over the skin, and in this way 
they sometimes accidentally introduce them into the external meatus. 

These may remain in place for a long time without causing any serious 
symptoms, and be overlooked by their parents and unnoticed by the 
child. 

In adults the introduction of foreign bodies into the external meatus 
is more apt to be accidental, or the result of some treatment, as the 
introduction of a bit of cotton which is allowed to remain long after it 
has served its original purpose. Bits of pencil, toothpicks, twigs, and 
straw may be introduced into the meatus during efforts to remove 
cerumen or moisture, and remain in the meatus until symptoms arise 
which cause them to seek relief from their physicians. 

Animate objects, such as roaches, fleas, flies, rosebugs, bedbugs, 
ixodes humanus, house-fly maggots, Texas screw-worms, and other living 
parasites are the source of great agony and discomfort when they enter 
the external meatus, on account of the clawing and twisting motion 
incident to their efforts to get food or gain egress from the cavity. The 
mode and place of sleeping influences the introduction of such objects 
into the meatus, as sleeping outdoors in a hammock or upon the ground, 
thereby inviting living insects to make their abode in this cavity. 

J. F. Church narrates a case in which a sheeptick had been in a stock- 
man's ear for two years. It was embedded beneath a mass of ceru- 
men and blood, and was still living when removed. The sensation was 
that of an intolerable scratching, accompanied by excruciating pain and 
deafness, which would suddenly pass away. There would be intervals 
of a month or more in which there would be no pain or discomfort in 
the ear. At times blood clots admixed with cerumen were removed. 

(G35) 



636 THE EAR 

When he came under the observation of Dr. Church the pain was, and 
had been, severe for about four days, and extended to the mastoid region. 
There was a feeling of numbness over the corresponding side of the 
face. The meatus was filled with cerumen and epithelium, which was 
removed with a spud and a syringe. This being done, the deeper portion 
of the meatus was exposed to view, and a moving body was seen. It 
presented the appearance of a perforation in the drumhead, with slender 
maggots protruding through it. 

The Texas screw-worm fly, or Compsomyia Lucilla macellaria, has 
been thought to be of Mexican or South American origin, although Dr. 
Williston, of Yale College, writes that "It grows especially from Canada 
to Patagonia." Its chief habitat in the United States, however, has been 
in Texas, hence its name. 

Its ravages among cattle are common, and often occasion heavy 
financial loss by the destruction of its victims. It more rarely invades 
the human family, but has been known to cause death in a number 
of instances. Its favorite point of attack in man is the ear or the nose. 
This is easily understood when it is known that the insect is attracted 
by foul-smelling odors. Those, therefore, affected with ozena or chronic 
otorrhea are especially likely to be invaded. The worm in the act of 
invading the tissues performs a sawing motion, and can penetrate bone. 
Mackenzie reports cases in which the cranial cavity was penetrated by 
them, and death from meningitis resulted. 

FOREIGN BODIES IN THE EAR 

Treatment. — It is important that caution be given as to the great 
harm that may be done by unwarranted, unskilful, or untimely efforts 
to remove foreign bodies from the external meatus. It should be remem- 
bered that foreign bodies, especially inanimate ones, can do little or 
no harm so long as they are left undisturbed in the meatus. This, of 
course, is not true for an indefinite period of time, but it is true in the 
sense that there is no need of haste on the part of the attending surgeon. 
More harm has been done to patients by the efforts to remove foreign 
bodies than has ever been produced by the presence of bodies in the 
meatus. If a foreign body is smooth and causes no pain or discomfort, 
there is certainly no occasion for its hasty removal; if it is rough, and 
causes considerable pain and discomfort, there is more excuse for its 
immediate removal; but even then it may be much wiser to allay first 
the irritation and swelling, after which it may be removed with compara- 
tive ease with either the syringe, snare, or forceps. 

I have seen cases in which the meatus was swollen and red from the 
unskilled attempts of members of the family to remove a foreign body. 
While thus swollen it was impossible for me to remove it immediately 
without a general anesthetic. In such instances I have first used anti- 
phlogistic remedies and soothing applications for a few days, after which 
it was comparatively easy to remove the foreign body without any great 
difficulty or pain to the patient. If an insect or other live body gains 



FOREIGN BODIES IN THE EAR 637 

entrance to the meatus, the first step to be taken is to render it lifeless, 
after which its removal can usually be effected with a syringe. 

Having thrown out this warning against meddlesome or unintelligent 
attempts to remove inanimate foreign bodies, we will discuss the best 
methods of procedure for this removal. 

1. First inspect the meatus in order to determine whether or not a 
foreign body is present, and if present, its probable nature. This is 
important, as the method of procedure for its removal will depend largely 
upon the character of the body present. 

2. Notice whether irritation or inflammation of the parts is present, 
and whether it is probable that the foreign body will do harm by remain- 
ing a few hours or days longer; and also as to whether it is probable that if 
immediate steps for its removal are taken, the effort would be rewarded 
by success. If the parts are swollen and inflamed to such an extent 
as to make it impracticable to remove it at once, it is better to wait until 
the swelling and inflammation are reduced by the use of hot, soothing 
lotions, and the application of leeches to the tragus. After a few hours, 
or at the most a few days, the swelling and painful condition will have 
subsided, thereby rendering the removal of the offending object a matter 
of comparative ease with little discomfort to the patient. 

3. Syringing should first be tried, as the stream of water may be forced 
into the meatus beyond the foreign body, and thus dislodge it from 
the external auditory meatus. The position of the head should be con- 
sidered in this and other methods of procedure, as the force of gravity 
will oftentimes materially aid in the removal of the object. The head 
should, therefore, be inclined toward the affected ear. Zaufal found, in 
109 cases of foreign bodies in the external meatus, that he could remove 
92 of them with the syringe, thereby demonstrating that nearly 90 per 
cent, of foreign bodies may be removed by this method. I fear that in 
the average practitioner's experience 90 per cent, of the removals have 
been attempted with either forceps or the so-called "ear hook ;" whereas 
the 90 per cent, of successful efforts should have been accomplished 
with a syringe, while in the other 10 per cent, it may have been proper 
to resort to the forceps and ear hook. 

4. The agglutination method was recommended by Riverias in 1674, 
by Celsus in 1806, and was revived by Lowenberg in 1872. It con- 
sists in placing heavy glue on the end of a piece of tape or a camel's- 
hair brush, applying this to the foreign body in the external meatus and 
leaving it in position until the glue becomes firmly enough fixed to bring 
the foreign body with it when traction is exerted upon it. This is probably 
one of the best methods, for most of the cases, after syringing has failed. 
It is to be recommended on account of the absence of instrumentation, 
whereby the meatus is so often seriously injured. 

A strip of adhesive plaster may be introduced into the meatus, applied 
to the foreign body and heated by focussing the rays of light upon it 
with a convex lens. This softens the adhesive material and allows it 
to become fastened to the foreign body, after which it may be removed 
by traction upon the adhesive strip. 



638 THE EAR 

The agglutination method is not used as often as it should be, as most 
physicians mistakenly think that a pair of forceps or the foreign body 
hook, usually present in the pocket case purchased upon graduation, 
are the instruments par excellence for this purpose. 

5. The foreign body hook is, perhaps, less harmful in the hands of 
an inexperienced operator than the forceps, and is, therefore, to be re- 
commended as a better instrument for the removal of foreign bodies 
from the external meatus. It should be so introduced as to allow the 
short hook to pass inward with its side against the wall of the meatus 
until it passes beyond the foreign body, when it should be rotated to bring 
the hook back of the foreign body. Slight traction should then be made 
upon it, with the view of dislodging the foreign body from its position in 
the meatus. If it fails to do this, it should be withdrawn and reintro- 
duced in another position, thereby to find a point at which the body may 
be loosened. If the foreign body has passed beyond the isthmus of the 
meatus and is lodged in the recess formed by the membrana tympani and 
the floor of the meatus, the hook should be introduced above the foreign 
body, as there is greater space at this point for the outward movement 
of the impacted mass. The convexity of the floor of the external meatus 
forms a favorable fulcrum upon which the lower portion of the foreign 
body rests, while the upper portion makes the outward excursion. It 
will be necessary, however, in some cases to introduce the hook either 
posteriorly or anteriorly in order to slowly dislodge the mass from its 
fixed position. After this has been done, the hook should be introduced 
above the mass, completely dislodging it from its point of impaction. 
Its removal through the cartilaginous meatus may then be accomplished 
with ease and little discomfort to the patient. 

6. Various forceps, designed for the removal of foreign bodies from 
the ear, have been devised and placed upon the market, none of which 
serve a very useful purpose. Young practitioners have great satisfaction 
in the thought that they have a full equipment at their command for the 
removal of foreign bodies from the ear. Beyond the satisfaction they 
thus afford, the instruments are of little value. It is with such instru- 
ments that untold harm and irreparable damage have been done, and 
not a few lives have been sacrificed to the enthusiasm of their owners, 
The foreign body has, in many instances, been forced through the 
drumhead into the middle ear, where the physician has left it, and it 
was only discovered at a later period during a mastoid operation. 

After a time its presence in the middle ear gives rise to necrosis and 
serious infection, followed by intracranial complications, such as abscess, 
meningitis, or sinus thrombosis, thrombosis of the jugular vein, laby- 
rinthine necrosis, or transmission of infective thrombi to the lungs, the 
spleen, or the kidneys. 

Having thus briefly, but pointedly, suggested the dangers attending 
the use of foreign body forceps, it may be said that they have a useful 
place, limited though it be, in the armamentarium of the physician. 

The cautions given above are not for the purpose of discouraging the 
practitioner from using the foreign body forceps, but are intended to lead 



FOREIGN BODIES IN THE EAR 639 

him to use them with great circumspection after having tried all other 
means for the removal of the foreign body. Those devised by Dr. Samuel 
Sexton are, perhaps, the best upon the market (Fig. 386). They are so 
constructed that the toothed tips may be introduced at the sides of the 
body, while the blades remain practically parallel with the walls of the 
external meatus; this is a point of no small importance when we remem- 
ber that most forceps for this purpose are so constructed that when the 
blades are spread apart the tips are at such an angle as to be easily forced 
into the meatal wall as they are pushed inward beyond the foreign body. 
Whatever instrument may be used, great care and delicacy of manipu- 
lation should be exercised, to avoid laceration of the meatus. If the 
foreign body is removed, the laceration will be of small moment, as 
it can be properly treated and quickly healed; if, however, the efforts 
to remove the foreign body are unsuccessful, the laceration may become 
a very serious complication, as the parts cannot, for obvious reasons, 
be properly treated. Swelling, infection, and inflammation may take 
place, which will still further interfere with the removal of the foreign 
body. Great discomfort results, and the condition is a serious menace 
to the well-being of the patient. 

Fig. 386 




Sexton's foreign body forceps. 

7. Postauricular incision for the removal of foreign bodies is a very 
ancient method of procedure, as Paul of Aegina suggested its use. 
Von Troltsch, in his text-book on Surgical Diseases of the Ear, sug- 
gested that in infants the incision is most effective when made above 
the auricle in the squamous region, as this area is depressed at that 
age, thus admitting of easy access to the meatus without injuring the 
postauricular artery. He thinks the injury to the artery should not be 
done needlessly, as it is an important source of nutrition to the auricle. 
With our improved methods of surgery and asepsis, we do not now 
fear an injury to this artery, and would not, therefore, make the incision 
above the auricle with this object in view. The incision in this posi- 
tion is, however, undoubtedly best adapted for the removal of foreign 
bodies which cannot otherwise be removed from the meatus of an infant 
on account of the oblique angle it forms with the squamous plate. 
The roof of the osseous meatus is gradually formed by the development 



640 THE EAR 

of the squamous bone, and extends inward at an obtuse angle, thus 
affording a favorable field for the introduction of instruments for the 
removal of foreign bodies. In adults, von Troltsch suggests that the 
incision should be made posterior to the meatus, as its roof is now at 
right angles to the squamous plate. 

With the antiseptic and aseptic methods now in vogue there should be 
little hesitancy in making a free incision in much the same manner as 
described for mastoid operations. The wound may be closed at once, 
union by first intention taking place. The skin of the cartilaginous 
meatus should be elevated as in the mastoid operation and lifted from 
its position. The foreign body is thus fully exposed to view, the meatus 
is shortened and enlarged, and instrumentation for its removal becomes 
comparatively easy. The patient should be under the influence of a 
general anesthetic. A portion of the osseous meatus should be chiselled 
away, if necessary, in order to facilitate the removal of the foreign 
body. 

Urbantschitsch reports a case of an oat husk which entered the 
Eustachian tube while the patient .was chewing an ear of grain. It 
passed through the tube into the middle ear, and thence into the external 
meatus. 

ANIMATED FOREIGN BODIES IN THE EAR 

Treatment. — Great concern is usually occasioned by the entrance 
of an insect or other animate body in the external meatus, on account 
of the clawing and scratching and penetrating movements attending its 
presence. Great noises of the most distressing and horrifying character 
are sometimes present, due no doubt to the clawing and scratching 
against the drumhead. On account of the great mental disturbance 
of the patient, the physician should have well-formulated ideas as 
to the proper methods of procedure for the removal of the insect, as 
he will otherwise be led to resort to methods in his haste and anxiety 
which will probably be unsuccessful and will only add to the pain and 
discomfort of the patient. I would, therefore, make the following 
suggestions : 

(a) Avoid the use of instruments. It has been found by experience 
that animate objects are not readily removed by the use of forceps or 
other instruments. They have the power of clinging tenaciously to the 
skin of the meatus with little hooklets in the case of maggots, and with 
the feet in the case of fully developed insects. 

(b) Drown the insect. This can usually be done with oil; if oil is not 
at your command, water may be used instead. If maggots are within 
the meatus, a 50 per cent, solution of chloroform should be used for 
this purpose, as oil or water seems to have little power to cause their 
death. 

(c) If for any reason it is desired to remove them immediately without 
waiting to render them lifeless, the syringe should be used, as in this 
way they may sometimes be removed with great ease. On the other 



FOREIGX BODIES IN EUSTACHIAN TUBE AND MIDDLE EAR 641 

hand, the method is oftentimes not successful until they have been 
rendered lifeless by drowning. If maggots are present, the fumes of 
chloroform blown into the ear from the bowl of a pipe will almost 
instantly render them lifeless. Chloroform may also be dropped into 
the ear for this purpose, with more certain results. After they are 
rendered lifeless, the insects or larvae are easily removed with the syringe, 
and it will rarely be necessary to resort to the use of forceps. Should 
it become necessary, however, to resort to them, they should be used 
with great caution, as otherwise the meatus and drumhead may be 
injured. The use of chlorinated water is of value in rendering them 
lifeless, especially the larvae. It is not, however, as efficacious as 
chloroform. 

(d) The agglutinative method may be used for the removal of dead 
insects from the ear, as described under Foreign Bodies in the Ear. 



FOREIGN BODIES IN THE EUSTACHIAN TUBE AND MIDDLE EAR 

Mayer 1 reports three cases of foreign bodies in the Eustachian tube: 
one, a grain of corn, was in the bony portion of the tube, while the others 
were in the cartilaginous end. They may enter the tube either through 
the middle ear or the epipharynx. If there is a perforation in the drum- 
head, a small grain or other substance may enter the middle ear through 
it, and thence pass to the Eustachian tube. Foreign bodies which are 
unskilfully or roughly handled in the effort to remove them from the 
external auditory meatus may thus be driven into the middle ear, whence 
they may gain entrance into the Eustachian tube. 

The use of Eustachian bougies has, in the past, been a fruitful source 
of foreign bodies in the tubes from accidental breaking while being used. 
Formerly the bougies were armed with feathers, cotton, or hair, for the 
introduction of medicaments, and were, consequently, more likely to be 
broken in the tube. Better and smoother instruments are now used, 
hence the accident occurs less frequently. 

Voltolini has recommended the galvanocautery for the removal of 
firmly embedded organic substances, as beans, etc., from the meatus and 
the middle ear. At various sittings small portions are thus destroyed, 
until the whole is finally disintegrated and removed. This method of 
procedure should be attempted with great caution, as there is considerable 
danger of exciting inflammation of the contiguous parts. 

If the foreign body is so deeply and firmly embedded in the middle 
ear as to render it impossible to remove it by simple and direct methods, 
the postauricular incision, such as described under mastoid operations, 
should be made, and, if necessary, a portion of the bone of the meatus 
may be chiselled away. When it is thus exposed, an attempt should 
be made to remove it with a stream of water. Should this fail, forceps 
may be used. 

1 Monatsschrift f. Ohrenheilkunde, Jahrg. v, Nr. 1. 
41 



642 THE EAR 

Foreign bodies in the cartilaginous end of the Eustachian tube may 
sometimes be seen with a postrhinoscopic mirror as they protrude 
from the mouth of the tube. In such cases it is often possible to seize 
the protruding end with a pair of curved forceps through the mouth 
and thus remove it. If this cannot be done, the drumhead may be 
perforated by means of a V-shaped incision, if a perforation does not 
already exist, and air forced into the middle ear by means of a Politzer 
bag or other compressed-air apparatus with a suitable tip, applied 
at the external meatus. In this way the current of air may be made to 
enter the Eustachian tube and force the foreign body from its pharyngeal 
orifice. 

CERUMINOUS PLUGS 

Cerumen is the product of the ceruminous glands which are located 
chiefly in the cartilaginous portion of the external auditory canal. A 
few glands are also present at the commencement of the osseous portion 
of the canal. The cerumen is normally thrown off by the movements of 
the mandible (inferior maxilla) and by the exfoliation of the epidermis 
which lines the canal. When, however, from any cause the secretion 
becomes excessive in quantity, more tenacious in quality, or its discharge 
is mechanically obstructed, ceruminous plugs form in the canal and 
give rise to more or less disturbance of hearing. 

Etiology. — The etiology may be studied under (a) diseases of the 
canal and middle ear; (b) obstructive lesions of the canal; (c) modifica- 
tions in the character of the ceruminous secretion; (d) foreign bodies in 
the canal; and (e) improper methods of washing the ear. 

(a) The diseases of the canal and middle ear which cause ceruminous 
plugs may be subdivided into hyperemia of the skin of the canal, diffuse 
and circumscribed eczema, and otitis media catarrhalis. 

(b) Modifications in the character of the cerumen, as in increased 
adhesiveness and the admixture of epithelium and hairs, cause the reten- 
tion of the cerumen. 

(c) Foreign bodies in the external canal form the nuclei of ceruminous 
plugs. They may be solid substances, as beads, small stones, etc., or 
they may consist of dust, sand, or other finely divided particles. 

(d) Improper methods of washing the ears are often responsible for 
the presence of ceruminous accumulations in the canal. Irritating 
soap-suds are introduced, the epidermis macerated in it, and the glands 
overstimulated. A mild dermatitis results. The corner of a towel or a 
washcloth is often twisted and screwed into the meatus, causing still 
further irritation, and oftentimes pushing the cerumen into the osseous 
portion of the meatus, where it remains, forming a nucleus for still more 
extensive accumulations. 

Symptoms. — The symptoms vary according to the degree of occlu- 
sion, the position of the plug, the amount of secondary irritation and 
inflammation, and the preexisting or associated lesions in the middle ear 
and labyrinth. 



CERUM1N0US PLUGS 643 

If the occlusion of the canal is incomplete in an ear which is otherwise 
normal, there will be but little impairment of hearing; if, on the other 
hand, the canal is entirely closed, there is marked diminution of hearing. 
If the plug is dislodged into the fundus of the canal against the drum 
membrane, the disturbance of hearing and the discomfort are much 
greater. In some cases the plug causes severe inflammatory reaction 
of the tissue immediately contiguous to it, which adds to the discomfort 
and the impairment of hearing. Reflex pains in the mastoid region 
are not uncommon in this condition. 

If suppurative inflammation of the middle ear and the mastoid cells 
is present with the ceruminous plug, the symptoms are modified accord- 
ingly; that is, there is a mixture of the symptoms of the two conditions. 

Pain is a symptom which is present only when the cerumen is hard 
and exerts pressure on the inflamed walls of the canal. 

In general, it may be said that the patient complains of a feeling of 
fulness in the ears and the head, and occasionally of dizziness, vomiting, 
headache, stupor, facial paralysis, trigeminal neuralgia, brain irritation, 
eclampsia, blepharospasm, pain, etc. 

The hearing may suddenly change from good to bad, or vice versa. 
When the drumhead is perforated the plug may improve the hearing by 
acting as an artificial membrane. 

Diagnosis. — The diagnosis is made by inspecting the canal, either 
with a speculum or by lifting the auricle upward and backward. The 
plug appears as a yellow or brownish mass of greasy or granular 
material, which, upon probing, proves to be either soft, semisolid, waxy, 
solid, or hard as stone. 

It may be mistaken for cholesteatoma, dried blood, a foreign body, 
cotton stained with secretion, etc. In some cases there is an excessive 
exfoliation of epidermis, which, becoming admixed with hairs and 
cerumen, lodges in the canal, thereby causing its occlusion. In these 
cases we have to deal with a pathological desquamation of epidermis 
rather than with a hypersecretion of cerumen. 

Prognosis. — When sudden loss or diminution of hearing follows the 
introduction of water or other liquids into the meatus, the prognosis 
as to the hearing is good, as the disturbance is probably due to the 
swelling of the plug, which obstructs the canal. Cases complicated by 
either adhesive otitis or labyrinthine affections are not greatly relieved 
by the removal of the cerumen. 

If we apply the tuning fork to the vertex, as in Weber's test, and the 
sound lateralizes to the obstructed ear, we gain no information, as the 
lateralization might be due to either middle-ear disease or to the plug. 
If, however, it lateralizes to the unobstructed ear, we may suspect laby- 
rinthine involvement on the obstructed side. 

Treatment. — The only form of treatment to be recommended is the 
removal of the cerumen by forcible injections of warm water with a 
syringe. If the plug has a moist appearance, or is soft to the probe, the 
injections may be made at once; whereas, if it is hard and lustreless, 
it should first be moistened by instilling a few drops of a solution of 



644 THE EAR 

bicarbonate of soda and glycerin in water; this should be repeated 
three or four times daily for about three days. The addition of the 
glycerin is advantageous on account of its hygroscopic property, which 
maintains the plug in a moist state between the instillations. When 
softened it may be removed with a syringe or with a cotton-wound probe. 

In rare instances the use of a round-ended probe may become neces- 
sary on account of the firm adhesion of the cerumen to the meatus. 
Persistent injections will ordinarily remove all secretions. Dizziness, 
or even vomiting, is sometimes induced by the force of the stream, the 
intralabyrinthine pressure being disturbed by the inward movement of 
the foot plate of the stapes. 

Keratosis Obturans, or Epithelial Plugs in the External Meatus. — In 1874 
Wreden described this condition, calling it "keratosis obturans." It is 
caused by a chronic desquamative dermatitis, in which the epithelium 
is gradually thrown off and accumulated layer by layer in the fundus 
of the canal. More or less deafness results, according to the degree of 
occlusion and the proximity of the plug to the drumhead. It is often 
mistaken for cerumen, as its layers may be admixed with and its surface 
covered by it. A careful macroscopic or microscopic examination will 
clear the diagnosis. Mr. Richard Lake advances the theory that it is 
caused by a dry, scaly eczema, which is excited by a ceruminous 
plug, while Burnett suggests that it is due to an excoriation and slow 
exudation of dermoid cells, brought on by rough and clumsy attempts 
to clean the ear. 

Pain in the meatus is the most constant symptom. In rare cases it 
radiates around the ear and over the temporal region. 

After syringing the ear, the plug becomes whitish or grayish in color, 
on account of the removal of the outer layer of cerumen, which is readily 
soluble in water. It is firm and dense and more or less adherent to the 
walls of the meatus. After its removal, if placed in water, it does not 
soften and break up as cerumen does under like conditions. Its layers 
resemble sodden white parchment. 

Treatment. — Before proceeding to remove the plug with the syringe, 
it should first be gently separated from the walls of the meatus with a 
flat applicator. This allows the stream of water to pass around and 
behind it, and facilitates its expulsion. If, however, it does not readily 
come away it should be removed piece by piece with a probe or forceps, 
one hour often being required for its accomplishment. Children do 
not calmly submit to the procedure, as it is somewhat painful; an anes- 
thetic should, therefore, be given. Recurrences may be expected; hence, 
frequent examination and treatments may be necessary. 



CHAPTER XXXVI 

MALFORMATIONS AND NEOPLASMS OF THE AURICLE 
MALFORMATIONS 

Malformations of the auricle are of importance chiefly from a cos- 
metic point of view. The auricle plays such a small part in the function 
of audition that its entire absence does not materially influence the 
acuity of hearing. If, however, the auricle is so shaped as to occlude 
the meatus, it may materially interfere with the transmission of sound 
waves and thus impair hearing. In most cases, however, when there 
is a very marked defect there is also defective formation of the external 
auditory meatus, the middle ear, and the labyrinth; hence, diminution in 
hearing is usually due to other conditions than the changes in the auricle. 

The malformations may be of a great variety of forms, ranging 
from a plurality of the auricle to its entire absence. Between these two 
extremes the auricle may be deformed to a slight degree, or it may be 
overdeveloped or misshapen in almost every conceivable way. It may 
be either arrested or overdeveloped. One part may be overdeveloped, 
while in another the development is arrested. It is not uncommon to 
see in a large company of people ears which project very markedly 
from the head, and which often give rise, especially among school- 
children, to their possessors being called "yellow kids." The term 
"lop ear" is often applied to the same condition. 

The defect may be either congenital or acquired. If congenital, it is 
due to a lack of closure of the branchial clefts and to a disproportionate 
development of one or more of the six tubercles or centres of develop- 
ment of the auricle. It may be unilateral or bilateral, usually the former. 
The bones of the face upon the side affected are usually also arrested in 
their development. 

Stahl, in 1859, called attention to the fact that deformity of the auric- 
ular cartilage might be regarded as an indication of arrest of develop- 
ment of the skull, and that it bore a relationship to the development of 
the skull. Defective formation may consist of the entire absence of the 
auricular cartilage, although it is probable that in nearly every instance 
a careful examination will reveal a small cartilaginous growth beneath 
the skin. The arrest may take on the form of a simple shrivelling of 
the whole auricle, or a portion of it. On the other hand, it may consist 
of an excessive development of one part and a diminished development 
of another; or it may assume any irregular type of development, as a 
twisted shell, or it may be hooked, cone-shaped, fissured, or cauliflower- 
like in form. 

(645) 



646 THE EAR 

Sometimes the upper portion of the auricle is turned downward 
from above and compressed against the middle portion, as is seen in 
the old statues of Pan (Politzer); or it may have deep indentations or 
horizontal fissures, and in rare instances it may be spindle-shaped. 
The tragus may be twisted inward, so as to close the meatus, or there 
may be an absence of the auricle with the exception of the lobule, which 
may be free or adherent to the adjacent skin. The meatus was present 
in a case of this kind reported by Schwartze. It opened beneath the 
lobule and led upward and inward to the drumhead. 

The auricular appendages or supernumerary auricles, according to 
Virchow, consist of reticular cartilage, subcutaneous cellular tissue, and 
skin. They are usually located in front of the tragus, although they 
may be on the lobule, the side of the neck, or the shoulders. Saissy, in 
1829, advanced the theory that malposition of the auricle from an im- 
properly placed head-dress invariably led to arrest of development. He 
says: "Boys often wear their hats so low upon the head as either to push 
the ear outward and cause it to project from the head, or to compress it 
against the head and cause it to assume too close a position. The latter 
often occurs in females from confining the ears too closely with the head- 
dress. To remove the deformity, it is only necessary to correct the habit." 

Maschziker, in 1864, in his text-book on The Ear and its Diseases 
and Their Treatment, states that ears are placed in malposition by too 
tightly drawn caps on children. 

I have known mothers to bandage the ears of their little ones to bring 
them more closely to the head, even when their fathers had widely pro- 
truding auricles, and the children had evidently inherited the physical 
trait. Thus the scientific tradition still holds popular credence, and 
many a little child is made to suffer in consequence. 

Saissy's views on the subject of imperforation of the external meatus 
were more nearly correct, as he regarded it as usually associated with a 
congenital and irremediable defect of the middle and the internal ears. 
The etiology of auricular deformity is to be found in the disordered 
development of the organ of hearing. There is insufficient closure of 
the upper two branchial clefts, which arrests or accelerates develop- 
ment of one or more of the six tubercles or centres of development, as 
shown by Minot, Talbot and others. 

Classification. — Auricular deformities may be classed as follows : 

(a) Entire absence of the auricle. 

(b) Overdevelopment of the auricle (macrotia). 

(c) Plurality of the auricle (polyotia, supernumerary). 

(d) Arrested development of the auricle (microtia, shrivelled). 

(e) Distortions of the auricle (cat-ears — as in the statues of Pan — 
shell-, scroll-, hook-, spindle-, cone-, fissure-, and cauliflower-like for- 
mations). 

(J) Fistula in auris congenita is a remnant of the first branchial cleft, 
and was first described by Heysinger in 1870. It opens in front of the 
ear, either above or below the tragus, and is a blind canal filled with 
creamy secretion mixed with pus. When its mouth becomes closed 



MALFORMATIONS 



647 



Fig. 387 



the secretion accumulates within the canal, which may be felt as hard 
nodules beneath the skin. Fistula auris congenita is of slight impor- 
tance, and may be healed by laying it open with a knife and remov- 
ing the epithelial lining and bringing the parts together again, after 
which they unite by first intention, and thus obliterate the canal. Mild 
caustic applications may be applied within the canal to excite inflam- 
mation and adhesions for the purpose of closing the canal. 

Fig. 387 illustrates one of my cases of microtia. The drawing is 
from a plaster cast of the ear. The young man is healthy and has a 
normal ear upon the opposite side. The cartilages of the fragmentary 
auricle are not attached to the skull in any way except by the skin. 
There is an entire absence of the external auditory meatus, and bone 
conduction is nil upon this side. He came to 
me to have the ear "opened up," if I thought 
it advisable. As there was no bony meatus, 
and the autopsies on similar cases have 
shown the middle-ear apparatus and laby- 
rinth to be absent or quite rudimentary, I 
advised him to leave the ear as it was. 

Treatment. — Macrotia. — Figs. 388 and 389 
illustrate one of my cases of macrotia. The 
case was referred to me by F. G. Suker, 
for the reduction of the lop-ear. The boy 
was eleven years old, and presented numerous 
stigmata of degeneracy. His schoolmates 
called him the "yellow kid." It was, there- 
fore, decided to overcome the defect by 
operating upon the auricles. This was done 
under general anesthesia. 

The skin on the posterior surface of each 
auricle was incised with a knife, the line of 
incision extending in a curve from within one- 
fourth inch of the superior attachment of the 
auricle to within one-half inch of its inferior 
attachment. A second incision was begun at 

the upper point and extended backward and downward over the mastoid 
process one-half inch posterior to the attachment of the auricle, and made 
to join the inferior end of the auricular incision (Fig. 388). An ellipse or 
segment of skin not unlike a segment of orange peel was thus outlined. 
This was dissected from the auricle and the mastoid process. The second 
step of the operation consisted in cutting through the cartilage of the 
auricle, following the line of the auricular skin incision. The cartilage 
was then severed at the auriculomastoid junction, care being exercised 
to avoid cutting through the skin on the anterior surface of the auricle. 
The cartilage was next carefully separated from the anterior skin of the 
auricle (a). 

The third step of the operation consisted in closing the wound (Fig. 
389). This was done in such a way as to bring the auricle close to the 




Author's case of microtia. The 
external auditory meatus, middle 
ear, and labyrinth are absent. 



648 



THE EAR 



head, as the operation was done principally for this purpose. In order 
to do this, four deep stitches with silkworm gut were taken, so as to in- 
clude the auricular skin, the auricular cartilage, the fibrous tissue over 
the mastoid, and the mastoid skin. These were drawn firmly together 
and secured. Ochsner's continuous horsehair suture was then used to 
bring the edges of the skin together. 



Fig. 388 



Fig. 389 




A, operation for macrotia, or lop-ear. An 
elliptical piece of skin (a, b) has been re- 
moved from the posterior wall of the auricle 
and mastoid process, a, the area of cartilage 
to be removed from the concha of the auricle. 



The operation for macrotia, or large project- 
ing auricle: B, the sutured incision at the 
close of the operation; C, the cartilage removed 
from the concha of the auricle; D, the skin 
removed from the posterior aspect of the auri- 
cle and the mastoid process. 



The superficial sutures were removed on the sixth day and the deep 
stitches on the ninth day. 

The results of the operation were excellent. Before the operation 
the auricles at Darwin's tubercle were 3.5 cm. from the side of the head, 
and after the operation they were 1.5 cm. distant. Three months after 
the operation they were 1.25 cm. from the head. 



NEOPLASMS OF THE EXTERNAL EAR 

Othematoma. — Definition. — This is a disease of the auricle charac- 
terized by an effusion of blood between the perichondrium and the 
cartilage. It may occur spontaneously or from direct violence. When 
it occurs spontaneously it is probably due to degenerative changes in 
the bloodvessels of the fibrous bands which traverse the cartilage of 
the auricle. It is also probable that degenerative changes occur in the 
fibrous tissue. 

Etiology. — Dementia seems to have a close relationship to the disease, 
as it is commonly found in the insane. Inhuman treatment of this 
class of patients has been so often charged, and it is more than probable 
that traumatism accounts for it among them to a large measure. This 



NEOPLASMS OF THE EXTERNAL EAR 



649 



is rendered more than probable by the fact that most of the cases have 
involvement of the left ear, because the blow from the right hand of 
the attendant would strike this ear. It must not be presumed, however, 
that this is the only cause, as the degenerative changes above referred to 
would be expected in this class of patients. The ex-champion pugilist, 
"Battling" Xelson, has othematoma, which was caused by numerous 
blows upon the ear in a series of boxing matches in remote places where 
he did not have the opportunity of applying hot water. 

The condition is common among the wrestlers of Japan, traumatism 
being the probable cause. 

Symptoms. — The tumor forms quickly, and this distinguishes it from 
perichondritis, angioma, and other neoplasms. The rapid development 
after an injury is quite characteristic. Its color is bluish, and it is rounded 

Fig. 390 




Othematoma with ossification following a history of dementia and traumatism. 
(Dr. G. McAuliff's case.) 



and soft to the touch. It does not have the distinct fluctuation com- 
mon to fluid sacs beneath the skin, but offers a doughy resistance. If 
it is due to traumatism it is usually quite large, and often involves the 
whole or the upper portion of the auricle; whereas if it is idiopathic it is 
often quite circumscribed, being limited to a nodule in the concha or 
other depression of the auricle. It is most common on the anterior or 
concave surface of the auricle (Fig. 390). 

Pain is present in the traumatic variety, but is absent in the idiopathic. 
The tumor is opaque by transmitted light, whereas that of perichon- 
dritis is transparent. If the auditory meatus is occluded by the swelling, 
deafness and tinnitus are present. It should be borne in mind that the 
deafness may be due to the rupture of the eardrum from concussion. 
In the case of "Battling" Nelson, the hematoma became organized and 
caused permanent deformity. 



650 THE EAR 

Diagnosis. — The diagnosis is based upon the rapid development of the 
growth after an injury, the opaqueness by transmitted light, and the 
absence of febrile symptoms. In the spontaneous variety the rapid 
development of the tumor is quite characteristic. 

Prognosis. — The traumatic variety ends by resolution more readily 
than the idiopathic variety, except when there is extensive damage to the 
cartilage. If there are no reactive symptoms and the swelling dimin- 
ishes in size, the prognosis is favorable. Violent inflammatory symp- 
toms, on the other hand, necessitate opening the tumor, thus rendering 
the prognosis more unfavorable. In some cases there is recovery without 
visible deformity, while in others recovery occurs with great shrinkage 
or other deformity of the cartilage. 

Treatment. — The treatment should be symptomatic and modified to 
correspond with the peculiar pathology of the case. If, for example, the 
othematoma is due to degenerative changes in the bloodvessels and the 
connective tissue or the cartilage of the auricle, it would be wrong to apply 
massage to promote absorption, as such manipulation would probably 
provoke more hemorrhage. Such a procedure, if tried at all, should be 
deferred until regeneration has closed the interior wounds. Pressure 
bandages are also contraindicated for the same reason. The applica- 
tion of ice-bags or a Leiter coil may exert a favorable influence in 
preventing passive inflammatory swelling; and if it is already present, 
the cold reduces it somewhat. The application of heat is better treat- 
ment, as it promotes regeneration. Cooling lotions locally and cathartics 
may also be tried with some advantage. The inflammatory type should 
be incised and antiseptic dressing applied. 

Politzer recommends the puncture of the tumor in the early stage of 
its development. If this is not followed by relief, it is better to open it 
thoroughly by free incision, after which the contents are removed and 
the cavity packed with iodoform gauze. 

Angioma. — Symptoms. — The bright red or lurid patches which are 
not elevated above the surface of the skin are not included in this group 
of tumors. The term " angioma," as used here, refers to the cavernous 
tumors, which are bluish red in color and are made up of a series of 
venous sinuses or cavities of various sizes and shapes. They are often 
separated from each other by perforated fibrous septa, which afford 
free intercommunication of their blood contents. 

They may appear in the auricle, in the meatus, or in both. They 
may be either primary or secondary extensions from adjacent struc- 
tures. They vary in size but rarely grow larger than a small hen's egg. 
They are irregular in shape. Pulsation is occasionally present. Angi- 
oma is sometimes congenital, while in other cases it develops after trauma 
or after the gradual dilatation of the bloodvessels of the simple angioma, 
the bright red or lurid patches referred to in the preceding paragraph. 
Cases are on record of angiomata which appeared after the auricle 
had been frozen. 

The presence of pain depends chiefly upon the rapidity with which 
they grow. If of rapid development and large size, the pain is consider- 



NEOPLASMS OF THE EXTERNAL EAR 651 

able. Troublesome pulsation is another characteristic of angioma of 
rapid growth. 

Deafness is present in those cases in which the meatus is occluded. 
Reflex cough may also be present when the meatus is involved. 

Diagnosis. — Othematoma is the only tumor which might be con- 
founded with cavernous angioma. The former is of rapid growth, 
smooth in outline, and opaque by transmitted light; whereas angioma 
usually develops more slowly, is irregular in outline, and is transparent 
by transmitted light. 

Treatment. — The treatment should be addressed to the reduction of 
the blood contents of the tumor, which interfere with its circulation 
This may be accomplished in several ways. Electrolysis is, perhaps, the 
best method in growths of small or medium size. The needles con- 
nected with the positive pole of the battery should be thrust through the 
growth, while the negative (sponge electrode) pole is placed on some 
remote portion of the body. The positive pole liberates oxygen and 
acids, which coagulate the blood and soft tissues, thus contracting and 
obstructing the cavernous sinuses of the tumor. Should the negative 
pole be applied as recommended by Hovell, the results would be less 
certain, as the negative pole liberates hydrogen gas, which tends to 
liquefy the solid tissues. The negative pole is better adapted to use 
in fibrous tumors, on account of its liquefying properties. 

Multiple puncture of the surface with needle points and brushing the 
surface with nitric acid has been recommended in small growths. Both 
measures produce scar tissue, and thus cause contraction. 

Politzer recommends the passage of several silk sutures through the 
tumor. He first renders them aseptic and then saturates them in a solu- 
tion of the perchloride of iron. The iron coagulates the blood and the 
threads act as nuclei for the clot formations. 

The Paquelin cautery has been used in larger growths. Such treat- 
ment is necessarily limited to exceptional cases. 

Injections of styptic remedies, as carbolglycerin, iodine, and the 
perchloride of iron, are not safe procedures, as they may cause extensive 
sloughing and subsequent disfigurement from cicatricial contraction. 
Suppuration and perichondritis may also follow the injections, the 
auricle becoming shrivelled and reduced in size. 

Fibroma. — Fibroma of the external ear consists of spindle cells and 
connective tissue. It is usually the result of local irritation, as from the 
wearing of ear-rings, and is often found in negresses, who are peculiarly 
subject to fibromata, not alone in the external ear, but in other parts of 
the body. They vary in size up to that of a large walnut, are rounded 
in form, and may be pedunculated or sessile. They are usually located 
in the lobule, as this is the portion in which ear-rings are worn. They 
may appear elsewhere on the auricle or even at the entrance to the 
auditory canal. 

Treatment. — A small V-shaped incision, including the growth, may 
be made, and the cut surfaces brought together by skin stitches, thus 
causing very little disfigurement. If the growth is pedunculated it 



652 THE EAR 

is easily removed with scissors, and the base cauterized and dressed 
antiseptically. Large growths may be removed by excision, the parts 
being brought together as well as possible to avoid disfigurement. If 
necessary, a subsequent plastic operation may be performed to over- 
come the deformity. 

Cysts. — Like cyst formations in other parts of the body, those of 
the ear are the result of the plastic union of parts which are normally 
open or separated, i. e., the sebaceous glands of the auricle may become 
infected, their orifices closed, and the secretions retained in the dilated 
and inflamed glandular sacs. They are variable in size, are soft, and 
may remain stationary in their development for several years. 

Treatment. — The treatment of cysts of the auricle consists in a free 
incision into the tumor, the evacuation of its contents, curettement, and 
the application of the tincture of iodine to the surface of the cavity. A 
suitable surgical dressing should then be applied, and repeated daily 
while repair is taking place. 

Epithelioma. — The growth begins as a hard nodule, situated in the 
skin or the subcutaneous connective tissue; it grows slowly for a time, but 
later develops quite rapidly. It is in this stage that ulceration is likely 
to occur. The growth may be an extension from contiguous structures, 
or it may be primary in the auricle or the meatus. Of the sixty cases 
reported, nearly all occurred in patients more than forty years of age. 
Dr. J. S. Brown reports a case in a man, aged seventy-eight years. Epithe- 
lioma may begin as warty or fissured surfaces, which finally ulcerate and 
continue to spread by the formation of new tissue at the edge of the ulcer. 
This tissue rapidly undergoes disintegration, and the ulcerous process 
may spread until the entire auricle and meatus or even the neighboring 
structures are destroyed. 

The nodular enlargements on the auricle may be present several 
months before enlargement of the glands in the neck appears. Pain 
may not be a symptom until ulceration takes place; hence, in the early 
stage, epithelioma may be mistaken for fibroma. As the ulceration 
and the deeper extension of the growth progress, the pain increases, 
often becoming excruciating in character. The facial nerve may be- 
come involved, and facial paralysis develop. The auditory nerve may 
be affected, or hemorrhages may occur, and glandular enlargements 
develop, which may result fatally. Death may be due to septicemia, 
exhaustion, meningitis, thrombosis of the lateral sinus, or cerebral 
abscess. 

Treatment. — The treatment of epithelioma here, as elsewhere in the 
body, consists in the complete removal of the growth by excision. To 
accomplish this, it may be necessary to remove the auricle in part or 
entirely. The resulting disfigurement may be corrected by a subse- 
quent plastic operation or the adjustment of an artificial auricle. While 
the wound is healing, a vulcanized or a silver tube should be worn in the 
meatus to prevent cicatricial contraction. 

Sarcoma. — Sarcoma of the auricle is rare. When present, it may 
be of the round-cell variety, which develops rapidly and leads to an 



NEOPLASMS OF THE EXTERNAL EAR 653 

early fatal issue, or it may be of the fibrosarcomatous type, which grows 
slowly. This type may exist for many years without giving rise to 
marked symptoms. The round-cell variety is painful, as its rapid 
growth stretches the sensory nerves, and it is also often attended with 
inflammation in the parotid and the mastoid regions. 

The appearance of the tumor varies according to the variety and the 
rapidity of development. If it is of the fibrosarcoma type, it is smooth 
and covered with normal skin. If it is of the round-cell variety, the 
rapid growth causes the skin to become eroded and the seat of fungous 
granulations. The eroded surface secretes an unsightly suppurating 
material composed of debris, pus, epithelium, leukocytes, and blood 
corpuscles. The ulcerating surface often bleeds profusely. 

The external meatus may be the seat of round-cell sarcoma and, in 
extremely rare instances, of osteosarcoma. 

Diagnosis. — A portion of the growth should be subjected to micro- 
scopic examination. The round-cell sarcoma is pale on cross-section, 
and exudes a milky juice; it is composed almost entirely of round cells 
and thin-walled bloodvessels. The fibrosarcoma has a considerable 
quantity of intercellular cement substance, and the macroscopic appear- 
ance of the tumor is coarse-grained and firm. 

Prognosis. — It is obvious that this will depend upon the type of the 
growth, the round-cell variety being comparatively more speedy and 
destructive. In this type, death may result from intracranial extension, 
hemorrhage, or exhaustion. 

Treatment. — Early and complete removal of the growth is the best 
treatment. This may be done with the knife or the galvanocautery. 
If the growth cannot be completely removed, the parts continue to dis- 
charge offensive material. 

The Rontgen-rays have been used with some apparent success in 
superficial sarcomata, but we are not ready to recommend this method 
of treatment until further trial has demonstrated its real value. It is 
unsafe to try it in the round-cell variety, as the early surgical removal 
offers the only hope in this type of sarcoma. While using the Rontgen- 
ray treatment, extensions may occur, thereby rendering operative treat- 
ment hopeless. The rays are of special value, however, after opera- 
tion, as recurrences are less frequent or are delayed by their use. 



CHAPTEE XXXVII 

DISEASES OF THE AURICLE AND EXTERNAL MEATUS 

PERICHONDRITIS OF THE AURICLE * 

This is a rare affection and resembles othematoma. The upper 
portion of the auricle is usually involved, as the cartilage is chiefly 
found there. The lobule escapes, as it is free from cartilage. 

Symptoms. — If the inflammation occurs as a complication of furun- 
culosis of the meatus, the pain characteristic of that condition is present; 
whereas, if it begins in the auricle, the first symptom may be circum- 
scribed redness and swelling, which gradually spreads and becomes 
more severe, until it finally involves the whole of the cartilaginous 
portion, including the concha, or it may include the meatus. If the 
meatus is wholly occluded by the swelling, the hearing is impaired. 
Fluctuation soon occurs, and is due to the inflammatory exudate of 
viscid serum beneath the perichondrium. The natural contour of 
the auricle is modified by the swollen tissue, and its surface is reddened. 
The perichondrium of the entire auricle may become detached and 
thus interfere with the nutrition of the cartilage. This is a serious 
complication, especially if the secretion becomes purulent. Under such 
circumstances the cartilaginous auricle is apt to shrink or slough, and 
leave marked deformity. 

The greatest care should be exercised to prevent additional infec- 
tion when there is an abrasion of the skin and when an incision is made 
to evacuate the fluid beneath the perichondrium. 
Fig 391 Should active infection be present, many weeks 

or months may be required to check the progress 
of the disease, and even then the auricle will be 
greatly deformed. Perichondritis occasionally fol- 
lows the mastoid operation, especially when the 
plastic meatal flap includes the concha of the 
auricle. 

The deformity following perichondritis may be 
so slight as to attract no attention, or it may be so 
marked as to disguise completely the anatomical 
characteristics of the auricle. 

Treatment.— The early treatment should be 

antiphlogistic in nature, heat being the best 

agent. The Leiter coil (Fig. 391) should be 

applied over the auricle and hot water passed through it. A hot-water 

bag may also be used. A saline cathartic should be administered 

(654) 




HERPES OF THE AURICLE 655 

and leeches used around the auricle in conjunction with the heat. If 
fluctuation is present, an incision should be made to evacuate the fluid. 
The auricle should be cleansed before making the incision, to pre- 
vent the possibility of additional infection. The cavity should be care- 
fully but thoroughly scraped with a dull curette, and then cleansed 
with an antiseptic solution. If the infection is severe and granulations 
are present, the cavity should be swabbed with the tincture of iodine 
or the compound tincture of benzoin. Free drainage should be main- 
tained by the insertion of a gauze wick, over which the usual dressing 
of gauze pads should be placed and held in position with a bandage. 
The dressings should be changed every twelve hours. 

Subsequent operative measures may be undertaken to correct the 
deformity if it is sufficient to produce disfigurement. 



HERPES OF THE AURICLE 

The etiology is not always clear, although herpes is apparently caused 
by middle-ear disease. It is thought by some to be caused by malaria, 
and by others to be a neurosis. It is most common in adults. 

Symptoms. — The vesicular eruption is sometimes preceded by a 
stinging or burning pain, especially if the meatus is involved. The 
eruption is generally on the outer or concave surface of the auricle, 
which is supplied by the auriculotemporal branch of the fifth nerve. 
This is of interest, as the distribution of the eruption usually follows 
the terminal branches of this nerve. It is more rarely on the posterior 
or convex surface of the auricle, as the auriculotemporal branch of the 
fifth nerve does not extend to this region. 

The course and appearance of the eruption is about as follows: 

At first there is a reddened area, which becomes papular, then vesic- 
ular. The vesicles may become confluent and form bullae. The vesicles 
at first contain clear serum, which later becomes cloudy and purulent. 
The duration of the vesicular stage is limited to a few days, after which 
the vesicles dry up, leaving crusts and an occasional superficial ulcer. 

If the meatus becomes involved, more or less deafness and tinnitus 
is present. 

Treatment. — Tonics, purgatives, and outdoor exercise are indi- 
cated to improve the general health of the patient. Cool or cold morn- 
ing baths, or at least sponging of the neck and chest, are indicated to 
improve the tone of the vasomotor nervous system. 

The blisters should be protected by starch or boric powder and 
cotton- wool dressings. The fluid contents of the vesicles should be 
emptied, care being taken to avoid removing the elevated dermis, and 
exposing the underlying parts to the air. This accident is attended with 
considerable pain. Boric acid powder may be applied in suppurative 
cases. If the meatus is involved, boric acid should be blown into it. 



656 THE EAR 



HERPES ZOSTER OF THE AURICLE 

This is a vesicular eruption which appears on a reddened surface, 
although the area of redness does not extend much beyond the base 
of the blisters. The vesicles are arranged in groups and are quite 
painful. 

They most often appear upon the posterior surface of the auricle and 
the lobule, and more rarely upon the anterior or superior surface of 
the meatus. They still more rarely develop upon the anterior surface 
of the auricle. 

It is an affection of either the trigeminus or the great auricular nerve. 
In some cases it seems to be of ganglionic origin. 

The location of the eruption is determined by the distribution of the 
affected nerve. 

In rare instances the drumhead is involved, although the hearing 
may be but slightly affected thereby. Within a few days after the for- 
mation of the vesicles they burst, emptying their contents, after which 
crusts form at the site of the eruption. 

A few days later new epidermis forms, and unless there is a recurrence 
of the disease, complete recovery takes place. 

Treatment. — Although herpes has been recognized as a distinct 
disease for a long time, the treatment of it has not developed beyond an 
attempt to relieve pain and to prevent excoriations after the bursting 
of the vesicles. The internal administration of arsenic is often recom- 
mended with the idea of correcting the nervous disorder which is the 
chief cause of the trouble. It is doubtful, however, if it has any specific 
effect as a remedy. Anodyne remedies, such as the 5 per cent, ointment 
of the hydrochlorate of cocaine, may be applied locally with a fair 
degree of confidence that it will afford relief. Calomel dusted over 
the eruptions, especially after they have discharged their contents, in- 
duces healthy and speedy epidermization of the denuded surfaces. 



DERMATITIS OF THE AURICLE 

Dermatitis may be due to traumatism, exposure to heat or cold, and 
to a parasitic infection (Politzer). The treatment should consist of the 
application of solutions of lead. 

It occasionally happens that when there is an abrasion of the skin of 
the auricle or a loss of the integrity of the epidermis due to eczema, 
etc., erysipelatous infection may occur and lead to a much more severe 
type of inflammation. 

Treatment. — The treatment should be antiphlogistic, and weak 
solutions of ichthyol (1 to 5 per cent.) should be applied locally. 

Should the deeper tissues become involved and pus accumulate 
therein, free incision should be made and the parts treated according 
to aseptic surgical principles. 



FURUNCULOSIS OF THE EXTERNAL MEATUS 657 

Dermatitis from Exposure to Cold. — Symptoms. — Frostbite; chil- 
blain; dermatitis congelationis auricula. 

Etiology. — Exposure to extreme cold or prolonged exposure to moderate 
temperature, as in the autumn of northern latitudes, also the extreme 
thinness of the skin and slight amount of subcutaneous tissue separating 
it from the cartilage of the auricle, predisposes to dermatitis. 

The disease is characterized by the formation of nodules and excoria- 
tions, especially on the elevated portions of the auricle. 

In the extreme north the dermatitis is usually acute in character, and 
is attended with simultaneous freezing of the nose. More or less necrosis 
and gangrene, and partial loss of the auricle follows. 

The affection is most common in young chlorotic girls of northern 
climates, and always appears at the beginning of cold weather. It is 
more than probable that insufficient and improper food predisposes to 
its occurrence. These conditions, together with the unstable vasomotor 
system at the age of puberty, may be considered the chief etiological 
factors. 

Symptoms. — Ordinary frostbite is characterized by moderate swelling, 
redness, and circumscribed dermatitis. 

The nodules heal slowly or not at all, and become covered by bloody 
crusts. Even after the crusts disappear, the skin continues to exfoliate 
epidermis for a long time. In addition to these symptoms, which are 
apparent to the eye, there are lancinating pains, sense of heat, itching, 
etc., which cause the patient to scratch or rub the parts, thereby increas- 
ing the inflammation. 

Treatment. — In those cases which are due to extreme cold, snow or 
ice-bags should be applied. In the subacute varieties, Goulard's extract 
is serviceable. The auricle may be painted with iodine collodion, or 
camphor ointments. For the relief of the intolerable itching the following 
mixture is of value :, 

]$. — Collodion 3J 

01. ricini IT|xx 

01. terebinth Bj— M. 

Sig. — Apply locally to relieve itching. 

The frequent application of camphor ointment will relieve the itching. 



FURUNCULOSIS OF THE EXTERNAL MEATUS 

Synonyms. — Follicular inflammation of the external auditory canal; 
otitis externa; follicularis s. circumscripta. 

Etiology. — Furunculosis of the external auditory canal is a circum- 
scribed inflammation involving either the hair follicles or the sudo- 
riferous glands. As these organs are limited to the cartilaginous or 
external portion of the canal, the furuncles are not found in the deeper 
or osseous portion. The boils may occur without known cause, or they 
may be a part of a general furunculosis. They may occur in the course 
43 



658 THE EAR 

of suppurative otitis media and chronic eczema. Traumatism from 
attempts at cleaning the ears often causes them. Furunculosis most 
often appears in the spring and autumn, and is chiefly a disease of adult 
life, though I have seen cases in infants. General debilitating diseases 
or their sequela? predispose to it. 

Symptoms. — The hearing is but slightly affected in most cases, as 
the lumen of the canal is not completely obstructed. The pain is more 
or less intense, according to the depth of the inflammatory process. The 
furuncle does not always present the appearance of a boil, as the skin is 
tense and closely adherent to the cartilaginous meatus, thus preventing 
the usual elevated appearance. 

The auricle is extremely sensitive to the touch, and the movements of 
the inferior maxilla in mastication cause pain. The tension of the skin 
becomes so great that the patient is often unable to sleep. The swelling 
in the external meatus is more or less diffused on account of the close 
adhesion of the skin to the cartilaginous meatus, and with the inexperi- 
enced may be mistaken for the redness and swelling in the postsuperior 
portion of the meatus in mastoid inflammation. It is easily differen- 
tiated from it, however, by remembering that the swelling due to mas- 
toid disease is limited to the postsuperior wall of the osseous or deeper 
portion of the meatus, while that due to furunculosis is in the posterior 
and inferior wall of the outer or cartilaginous portion. The pain is 
often greater in furunculosis. In infants the differentiation is more 
difficult, as the meatus is very shallow and the swelling is near the mem- 
brana tympani, which it may obscure. 

The temperature is irregularly elevated during the first few days. 
Deafness and tinnitus are present if the meatus is occluded, though 
they may be present without occlusion. When this is the case the in- 
flammation has probably extended to the drumhead and the tympanum. 

The more superficial the furuncle, the greater the redness and the 
more circumscribed its area. Pain may or may not be present. If the 
deep tissues are involved the redness and swelling are more diffused, 
while the pain is greater. In some cases the surrounding tissues become 
more or less swollen, as, for instance, when the anterior portion of 
the meatus is involved, the skin in front of the tragus is swollen and 
purple in color; whereas if the posterior portion is involved, the mastoid 
skin may be swollen and simulate mastoiditis. Glandular enlargement 
in the lateral region of the neck is not commonly present. 

Course. — Furunculosis of the meatus is likely to go on to suppuration, 
which usually takes place in from six to eight days. The deeper the 
inflammation the more delayed the voluntary escape of pus. The pain 
and swelling subside immediately after the pus is liberated, especially 
if it is done by incision. . Incision should be made early, as the progress 
of the disease is often thereby checked. The meatus should then be 
irrigated' with warm boric acid solution, thoroughly dried and dusted 
with bismuth, and a gauze wick inserted for drainage. The dressing 
should be changed daily until the swelling and discharge have materially 
subsided. If the boil is allowed to rupture spontaneously granulations 



DIFFUSED INFLAMMATION OF THE EXTERNAL MEATUS 659 

may spring from its crater, and be mistaken for middle-ear polypus. 
Recurrences are to be expected in many cases. 

Treatment. — Abortive treatment may be used before the forma- 
tion of pus has taken place. The best remedy is a 12 per cent, solution 
of carbolic acid in glycerin. This should be instilled into the meatus, 
or applied with a cotton-wound applicator if the canal is open. Its 
early use is often followed by a complete disappearance of the process. 
The Leiter ice coil gives relief to the pain. Mixtures containing opium, 
morphine, cocaine, etc., are recommended, the carbol-glycerin mixture, 
however, is not only curative, but analgesic as well. Poultices have 
been recommended, but their use is irrational and obsolete. Antiseptic 
solutions are valuable adjuncts in the treatment of furunculosis, and 
the carbol-glycerin solution answers this purpose admirably, in addi- 
tion to its anodyne and curative properties. Should it fail to give the 
desired relief, the meatus is at least prepared for operative measures. 

In a large majority of cases the process has gone on to the suppurative 
stage before the physician is called in. When pus is present, the furuncu- 
lous area should be freely incised with a narrow bistoury. Pus may not 
appear at once, but this should not deter the physician from incising 
each swollen and reddened area. If voluntary rupture has occurred 
and the flow of pus is obstructed by granulations, the area should be 
opened more freely. 

After-treatment. — Immediately after incision, the exposed cavities 
should be cleansed with a 5 per cent, solution of carbolic acid to check 
the growth of the pus cocci. Frequent instillations of the peroxide of 
hydrogen should be used to keep the wound and the meatus free of pus. 

The ceruminous secretion is often absent after an attack of furuncu- 
losis, or, if present, is of a dry, crumbling quality. Intolerable itching 
usually complicates furunculosis. 

Various remedies for the relief of the itching have been recommended. 
The white precipitate ointment, boric acid 5 per cent, in lanolin, and 
the glycerin-carbolic acid solution are valuable for this purpose. 

The entrance of plain water into the meatus often leads to a relapse, 
hence care should be exercised to prevent it. 



DIFFUSED INFLAMMATION OF THE EXTERNAL MEATUS 

Synonym. — Otitis externa diffusa. 

Etiology. — The causes are (a) infections from without or from 
within the middle ear; (b) traumatism; (c) excoriation of the cutis of the 
meatus; and (d) the injection of irritating fluids into the meatus. 

Symptoms. — Unlike the furunculous type, the symptoms are chiefly 
limited to the osseous meatus and the drumhead. The cutis is swollen 
and congested, and after a few days throws off a serogelatinous secre- 
tion, which is often so tenacious that it can be removed en masse (PolitzerV 
It is charged with pathogenic organisms, thus showing its bacteriological 
origin. 



660 THE EAR 

Great pain in the region of the ear is usually present, and movements 
of the inferior maxilla aggravate it. Tinnitus and dizziness are occa- 
sionally present. The hearing may be impaired, especially if the 
drumhead is much swollen, or if there is a large accumulation of thick 
secretion. 

The duration of the disease is three or more days. If it runs an un- 
interrupted course, an acute case may terminate on the third day. The 
hearing is usually normal after the inflammation ceases. In rare cases 
an excoriated or ulcerous surface is left, and becomes the seat of a granu- 
lation tumor, which, when removed, checks further secretion of pus. 

Periostitis and hyperostosis may remain as sequelae in rare cases. 

Prognosis. — In the simple forms, complete recovery usually occurs, 
while in those cases which are complicated by excoriations, constriction 
of the meatus from periostitis, hyperostosis, and dermoid thickening are 
likely to affect the function of the ear. 

Treatment. — It should be borne in mind that the disease is usually 
of bacteriological origin, and remedies should be applied accordingly. 
The carbol-glycerin mixture (12 per cent.) is, perhaps, one of the most 
reliable remedies. It should be instilled into the meatus two to three 
times daily and cotton- wool introduced into the cartilaginous canal. The 
Leiter coil, and leeches to the tragus and the mastoid region are of great 
value when there is swelling and pain. Antiseptic solutions of all kinds 
have been recommended, but it is doubtful if any of them are of special 
value. It may be said of aqueous solutions in general that their utility 
is questionable. Remove the secretions from the meatus with the 
peroxide of hydrogen and a cotton-wound applicator and then apply 
carbol-glycerin mixture. 

If ulcers form and show no tendency to heal, they should be cauterized 
with a 90 per cent, solution of the nitrate of silver. 



HEMORRHAGIC INFLAMMATION OF THE MEATUS 

Synonym. — Otitis externa hemorrhagica. 

This is a form of hemorrhage beneath the superficial layer of the skin 
of the osseous meatus, and in most cases is probably a complication of 
influenza otitis media. The hemorrhagic areas appear as bluish swell- 
ings on the inferior or the posterior wall of the meatus. To the probe 
they are soft and often rupture upon very slight pressure. The vesicles 
may remain for several days, and when they disappear others may come 
to take their place. In from one to two weeks they disappear altogether, 
and complete recovery takes place. The hearing, if affected, returns to 
normal. 

Treatment. — The hemorrhagic vesicles should be opened with a 
probe and gauze drainage applied to the meatus. The dressing should 
be removed daily. Politzer recommends dusting the meatus with boric 
acid powder in addition to the gauze drainage. 



EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS 661 



CROUPOUS INFLAMMATION OF THE MEATUS 

Synonym. — Otitis externa crouposa. 

This is a very rare condition, and usually occurs together with in- 
fluenza otitis media or furunculosis of the meatus. The false mem- 
brane is limited to the osseous portion of the meatus and to the outer 
surface of the drumhead, and in this is similar to the diffuse inflamma- 
tion of the meatus. It sometimes appears with a similar process on 
the tonsils (Gottstein). The membrane forms in from one to two 
days and is firmly attached; it may, however, be removed by forcible 
syringing. It may form a cast of the osseous meatus and the drumhead. 
The microscope shows it to be composed of a fibrous network infiltrated 
with round cells, nuclei, epithelium, Staphylococcus pyocyaneus, and 
Streptococcus pyogenes (Politzer). 

The formation of the membrane is attended with some pain which is 
relieved when it is cast off. Recurrences are common. 

Prognosis. — The prognosis is favorable. In rare cases the cartilage 
of the meatus becomes necrotic or gangrenous. 

Treatment. — The treatment consists in removing the false mem- 
brane with forceps or by antiseptic solutions applied with a syringe, 
and drying the meatus and dusting it with an antiseptic powder. 



EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS 

These two terms are often used synonymously, although, according 
to strict pathological interpretation, they should be used to describe 
different lesions of the bony tissue. 

An exostosis is a bony tumor growing from the wall of the meatus, 
which may be either sessile or pedunculated. Hyperostosis is a diffuse 
thickening of the bony tissue, or a true hyperplasia. 

Etiology. — The cause of these pathological changes is often unknown, 
but in many instances they are due to conditions which may be easily 
recognized. Among them may be mentioned. 

(a) Traumatic fracture of the walls of the meatus, whereby a cir- 
cumscribed periostitis is excited, which finally results in the formation of 
a bony mass or tumor. 

(b) They may be due to developmental causes, particularly in those 
cases wherein the middle and the inner section of the osseous meatus on 
each side is the seat of the growth. When due to faulty development, 
the growths are usually small. They may be either sessile or peduncu- 
lated. 

(c) Chronic suppuration of the middle ear may excite a secondary 
inflammation of the membranous canal, and cause a fibrous or con- 
nective-tissue thickening, which, after a long period of time, may be 
metamorphosed into osseous tissue 



662 TEE EAR 

(d) There are some cases in which heredity seems to be a factor in the 
production of the growths, as the same condition may be traced through 
a few generations. 

(e) Syphilis is undoubtedly a cause of the growths, although not in 
a very large number of cases. 

(J) Gout has been thought to be another cause, but it is doubtful if 
this condition leads directly to their formation. 

It is more probable that the gouty diathesis causes an inflammatory 
process of the skin and the periosteum, which finally undergoes a retro- 
grade change and becomes the seat of lime deposit. 

Symptoms. — The symptoms are chiefly those recognizable by the aid 
of the eye and the probe, although in some cases in which the lumen of 
the ear is completely occluded, the function of hearing may be affected. 
If the growth is an exostosis, it appears as a rounded, elevated mass, 
with a tense, whitish covering of skin. The lumen of the meatus is 
reduced to a crescentic or slit-like opening. The swelling or growth is 
composed of very dense tissue. If it is sessile, it will be difficult to dif- 
ferentiate between it and a hyperostosis; but if it is pedunculated, the 
differential diagnosis may be more easily made, as this type of growth 
is more often an exostosis. A favorite seat for the growths is at the 
junction of the osseous and the cartilaginous portions of the meatus. 
They may, however, form in any portion of the canal. Deafness may 
be present, although it is not marked, unless there is concurrent disease 
of the middle ear or the labyrinth, except in those cases in which the 
growth completely obstructs the lumen of the canal. Secondary inflam- 
mation of the cutaneous meatus may be caused by the pressure of the 
growth against the opposing walls. In such cases there will be more 
or less secretion from the dermatitis thus excited. Cases have been 
reported in which the pressure of the growth was so great that necrosis 
of the surrounding bone tissue resulted, thereby complicating the case. 

Treatment. — The treatment is necessarily limited chiefly to surgical 
procedures, except for the relief of those symptoms which are due to 
secondary inflammatory processes. If the growth is large enough to 
interfere in any way with the function of audition, it should be removed. 
In some cases this can be done through the external auditory meatus 
without lifting the auricle forward, as is done in the mastoid operation. 
The skin and periosteum over the growth should be excised and elevated, 
and the bony mass removed or reduced with a small chisel or gouge 
or with a trephine. If the growth is sessile or diffused, and involves 
the entire length of one wall of the meatus, it would, perhaps, be futile 
to attempt to remove it through the external auditory meatus. A better 
and much simpler procedure would be first to lift the auricle forward, 
as in the mastoid operation, thus exposing the entire canal to view and 
affording easy access with instruments. When this is done, the skin of the 
osseous portion of the meatus should be carefully elevated with a small 
periosteum elevator, so that the healing process may be more certain 
and rapid after the operation. The exposed tumor should then be re- 
moved with a very sharp gouge, or, perhaps better still, by the use of a 



STRICTURE OF THE EXTERNAL MEATUS 663 

trephine. This method of procedure is also productive of better results 
in many of the pedunculated growths, as the base can thus be completely 
removed. 

The indications for operative interference should be based upon the 
amount of deafness present and upon the concurrent middle-ear disease, 
if present. If, for example > there is chronic suppurative ear disease, 
with impairment of hearing, it is quite essential to the proper treat- 
ment of the case that the external auditory meatus be completely freed 
from the obstructive lesion, so as to afford better drainage and opportuni- 
ties for treatment of the middle-ear cavity. 

Another indication is the presence of dermatitis with secretions, while 
a still more urgent indication is secondary pressure necrosis of the con- 
tiguous tissue. 

It seems irrational, in view of the present status of surgery, to resort to 
the use of laminaria tents for the dilatation of the canal, as the process 
must necessarily be a long and painful one. This method was formerly 
in vogue and is still recommended in some of the modern text-books on 
otology. 

STRICTURE OF THE EXTERNAL MEATUS 

Etiology. — Obstructive lesions of the external auditory canal are 
due to the inflammatory swelling of the skin which lines its walls, as 
described under dermatitis, furunculosis, perichondritis, eczema, etc. 
It may also be due to newgrowths, exostosis, and fibrous thickening 
of the deeper dermal tissue. It is to the last-named condition that 
permanent obstruction of the lumen of the canal is usually due. 

Cicatricial rings or bands are produced by prolonged inflammation 
of the meatus in the course of chronic otorrhea. In rare instances they 
are due to syphilis, diphtheria, etc., or to the use of the cautery and acids 
in the meatus. Partial closure of the canal sometimes follows the mas- 
toid operation, especially if the plastic meatal skin flap is not properly 
sutured and the wound is tightly packed with gauze. (See Mastoid 
Operation.) In the aged the cartilage which supports the skin of the 
meatus undergoes atrophic changes, which allows the walls to collapse 
and obstruct the meatus. 

In some cases the obstructive lesion is ring-like, while in others it may 
be limited to one wall of the meatus. If it is due to an exostosis, there 
is a tumefaction on one side of the canal. The tumor is hard to the 
touch of the probe, and may either partially or wholly obstruct the meatus. 
Exostosis sometimes follows the exfoliation of necrosed bone, while in 
other cases it develops from the periosteum or from the bone beneath, 
as true hyperostosis. 

Treatment. — As the origin of the obstruction is various, so should 
the treatment be varied. If inflammatory, suitable treatment should be 
instituted. If it is cicatricial in character, laminaria tents and the sub- 
sequent introduction of hard rubber tubes may be used. In this way 
the stricture is dilated and maintained in this condition by the rubber 



664 THE EAR 

tubes. Electrolysis may also be used with advantage; from five to six 
sittings are required to reduce the fibrous constriction. The needles 
connected with the negative pole of the galvanic battery should be 
inserted into the fibrous ring, while a large sponge electrode connected 
with the positive pole should be placed in contact with the body. The 
amount of current necessary to soften the tissue varies from 25 to 50 ma., 
and each seance should last from five to twenty minutes, according 
to the amount and density of the fibrous tissue. 

Another method of treating fibrous strictures is to split the canal 
longitudinally in several parallel lines and introduce sponge tents. 

After thorough dilatation the hard rubber tubes should be used to 
maintain the patency of the meatus. 

Jansen resorts to a surgical procedure, which is probably the most 
successful mode of treatment, whether the stenosis is cicatricial or 
osseous in character. He detaches the auricle as in the mastoid opera- 
tion, and then dissects away the fibrous ring, osteoma, or hyperostosis. 
To cover the bony wound, he makes a pedunculated flap from the skin 
over the mastoid process and inserts it through the line of incision made 
in detaching the auricle. 

Should the stricture be of long standing and accompanied by sup- 
puration of the middle ear, a radical mastoid operation should be done, 
during which the canal may be enlarged. 



MYCOSIS OF THE EXTERNAL MEATUS 

Synonyms. — Parasitic inflammation of the external auditory canal; 
otomycosis. 

Etiology. — The source of the mycotic infection is often unknown. 
Living in damp surroundings or in the presence of yeast spores seems 
to favor it; hence, it is rather common among bakers. The habit of 
instilling warm oil into the ears to relieve earache favors the growth 
of the spores, as the oil is a good soil for their development. The spores 
which most commonly cause the disease are the Aspergillus niger, flavus, 
and fumigatus. Several other varieties are occasionally found. 

It usually occurs in adults, and rarely in children or in the old. As the 
sanitary and hygienic conditions surrounding the poor are bad, it is 
common among them. The fungus growth may, in rare cases, extend to 
the middle-ear cavity or even to the mastoid cells. 

Symptoms. — The manifestations of the infection depend largely 
upon whether the spores have attacked only the epidermis or also the 
deeper living structures of the skin or the drumhead. If only the epi- 
dermis is affected, there may be no symptoms, even when the drumhead 
is covered with the false membrane; on the contrary, if the true skin is 
involved, deafness and tinnitus are more or less severe as a result of 
the swelling and inflammation which has been excited. This type of 
inflammation is known as otitis externa parasitica, and is characterized 
by shooting pains, itching, tinnitus, and deafness. 



ACUTE ECZEMA OF THE EXTERNAL EAR 665 

The appearance of the mycotic membrane is black or grayish in color, 
velvety in texture, and distributed chiefly over the osseous portion of 
the canal, although the drumhead and the cartilaginous portion of the 
canal may also be covered by it. It can be removed by syringing. The 
underlying skin is red, slightly swollen, and largely denuded of epidermis. 

The course of this type of inflammation, if not properly treated, may 
extend over several weeks. Under treatment its duration may be much 
shortened. 

The pains and other subjective symptoms are usually greatly relieved 
immediately after the removal of the membrane. 

Treatment. — Almost the entire list of antiseptic mixtures and powders 
have been used for the relief of this disease, but the remedy par excel- 
lence is alcohol, which should be instilled into the meatus once or twice 
daily; two to four days are usually sufficient time to effect a cure. The 
alcohol should be used at intervals of every two weeks for a few months 
to prevent a recurrence. 

ACUTE ECZEMA OF THE EXTERNAL EAR 

The superficial layers of skin are involved, and, in the beginning, 
there is marked redness and swelling of the skin; nests or colonies of 
fluid-filled vesicles soon make their appearance. 

Etiology. — It is not always possible to ascribe a cause for the erup- 
tion, although it is usually due to one or more of the following factors: 
viz., neurosis, scrofula, rickets, discharge of pus from the middle ear, 
irritating remedies, cold douches, and exposure to heat. Other causes 
exist in selected cases. It may be a primary affection or it may be 
secondary to a similar process on some other part of the body. 

Symptoms. — The onset of the disease is characterized by burning 
and itching, which is soon followed by pain. Deafness and tinnitus are 
present in those cases in which the meatus and the drumhead are in- 
volved, especially when the exfoliated epidermis and secretions obstruct 
the lumen of the canal. If the disease is limited to the auricle, the hear- 
ing is not affected. There is some elevation of the temperature, especially 
in children. The pain and the pyrexia give rise to restlessness and 
inability to sleep. 

The disease may terminate in one of three ways, namely: (a) In the 
mild form the vesicles dry up and the epidermis peels off on the second or 
third day, leaving the natural cuticle, (b) In a large number of cases 
the blisters discharge their contents, and after a few days the surface 
becomes covered with yellow crusts. In time these disappear and 
recovery takes place, (c) The third and most disagreeable mode of 
termination is the persistence of serous or purulent secretion for several 
weeks, after which the parts become covered with epidermis. 

In some cases the eczema may persist in isolated areas for many weeks 
and leave more or less scar tissue and contraction, or it persists and 
becomes typically chronic in character. 

The treatment will be considered under Chronic Eczema. 



666 THE EAR 



CHRONIC ECZEMA OF THE EXTERNAL EAR 

Symptoms. — Owing to the involvement of the deeper structures o>I 
the skin, there is greater thickening and rigidity of the auricle than in the 
acute type. The crusts usually form in the hollows of the auricle and in 
the posterior groove, while beneath them is secreted a serous or purulent 
matter. The meatus may be obstructed by the thickening of its integu- 
ment. The whole auricle, and in some cases the meatus, is the seat of a 
desquamative process. The process of desquamation and crust forma- 
tion varies in different cases, although the desquamation is usually 
predominant. 

Exclusive of the appearance of the skin, the itching is the most severe 
symptom. The patient is overcome with an irresistible desire to rub 
or scratch the parts, and thus produce deeper lesions of the skin. 

Tinnitus and deafness may result from desquamative plugs in the 
meatus and from secondary hyperemia of the mucous membrane of 
the middle ear. It is barely possible that in rare cases hyperemia of the 
labyrinth may be induced. 

The course of chronic eczema is quite different in individual cases, 
some are cured under treatment in a few weeks, while others obsti- 
nately persist under any form of treatment. Boils in the meatus may 
complicate the condition. 

Treatment. — The general treatment should be addressed to the 
correction of constitutional dyscrasias and neuropathic states, which so 
often underlie the condition. Iron, arsenic, strychnine, iodine, and the 
bitter tonics should be given in suitable combination for this purpose. ■ 
The administration of saline cathartics and an occasional dose of calomel 
will often aid in overcoming the eczema. 

Perhaps one of the best measures for its relief is negative in character, 
namely, the avoidance of the local application of water, which greatly 
aggravates the eczema. If it is desirable to use water for toilet pur- 
poses, the patient should be instructed to add boric acid or a teaspoonful 
of common table salt to the quart of water. The irritating qualities of 
the water are thus reduced. 

The local treatment is somewhat different in the acute and the chronic 
forms, hence they will be considered separately. 

Local Treatment of Acute or Subacute Eczema. — The remarks concerning 
the avoidance of plain water are especially applicable to this type of 
eczema. If proper care is exercised, some cases will be cured with no 
local or constitutional treatment whatever. Others will persist in spite 
of any mode of treatment, and gradually pass into the chronic form. A 
soothing ointment composed of one dram of the oxide of zinc to the ounce 
of lanolin or vaseline is very sedative, especially if the disease is due to an 
irritating discharge from the middle ear. The addition of one grain of 
the acetate of morphine will increase the sedative action of the ointment. 
Calomel dusted on the excoriated or fissured surfaces acts well in some 
cases. Lotions of liquor plumbi subacetatis and resorcin are indicated 



CHRONIC ECZEMA OF THE EXTERNAL EAR 667 

when there are large vesicated surfaces. As their application excites 
pain, the parts should previously be painted with a 5 per cent, solution 
of cocaine. Ichthyol in aqueous solution (2 to 50 per cent.) has proved 
a valuable remedy. The parts should be painted once or twice daily. 
Cotton pads may be applied over the painted surface to prolong the 
therapeutic effect of the remedy and protect the diseased area from 
the air. 
When the case is in the crust-forming stage proceed as follows: 

(a) Remove the crusts by first softening them for twenty-four or 
forty-eight hours by local applications of oil, vaseline, lanolin, balsam of 
Peru, or a 10 per cent, solution of Burow's mixture. If the oily prepara- 
tions are used, cotton should be saturated with them and applied over 
the scabs, and protected by another pad of gauze lightly held in position 
by a bandage. If Burow's mixture is used, the pads of cotton saturated 
with it should be covered with oiled silk or rubber cloth to prevent evapo- 
ration. Change every two hours. 

(b) At the end of twenty-four hours, the crusts may be removed with 
a probe or forceps. Great care should be exercised to avoid inflicting 
injury to the underlying surface, as to do so causes a larger crust to 
form. 

(c) The parts are now ready for the medicated ointments referred to 
above. They should be changed every day. The parts should be care- 
fully cleansed each time by wiping them with cotton pads, water being 
carefully avoided. If the crust formation is obstinate, the parts should be 
painted with a 1 to 3 per cent, solution of the nitrate of silver before 
reapplying the salve. 

(d) When epidermization is established, the new skin should be pro- 
tected from mechanical or chemical (water) irritants by the use of 
simple ointments for several weeks. If this is not done, recurrences 
are likely to take place and the hyperemia which is present in this stage 
may be exaggerated. 

Local Treatment of Chronic Eczema. — It is rather difficult to outline a 
definite procedure for the treatment of chronic squamous eczema, as so 
many remedies are recommended, none of which may be depended upon 
except in selected cases. 

Those remedies which soften the scaly epidermis and reduce the hyper- 
emia of the skin afford the best results. 

To soften the scaly epidermis, vaseline, lanolin, or olive oil should be 
rubbed in once or twice daily; or a 10 per cent, solution of Burow's 
mixture may be applied as described above. 

After thus softening and removing the horny layer, the parts should 
be painted with a 10 to 20 per cent, solution of the nitrate of silver. The 
author has used this method after the suggestion of Politzer, with the 
greatest satisfaction. An immediate cure should not be expected, as 
several weeks are often necessary to effect it. 

Fissures or cracks at the external auditory orifice are best treated with 
solid nitrate of silver or salicylic acid ointment. 



THE EAR 

Nearly all the ointments in the Phannacopoeia have been used in 
eczema, but further mention of them need not be made here. If the 
treatment according to the above principles fails, the case is probably 
one which will resist all treatment. In the event of failure, special care 
should be observed to soften thoroughly the scaly epidermis and to 
remove it, and then the silver solution should again be used. Many of 
the failures are due to the non-observance of this procedure. 



CHAPTEE XXXVIII 

MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI 

In early life the upper portion of the membrana tympani may be absent, 
with no history or previous suppuration. This is explained by the fact 
that in the embryo this is the last portion of the membrane to form, and, 
the process not being complete, a perforation or opening persists. Von 
Troltsch suggested that some of the perforations just above or behind 
the processus brevis mallei, such as are seen in otorrhea, are congenital, 
but have become enlarged by a subsequent suppuration within the 
tympanum. This observation may be questioned in certain particulars, 
in view of the fact that the location of the perforation is usually indicative 
of the character and seat of the middle-ear involvement. For instance, a 
perforation in the region of the processus brevis mallei usually indicates a 
necrosis of the malleus, and possibly, also, of the tegmen tympani. We 
find that the perforation appears as readily in other portions of the mem- 
brana tympani if the focus of the middle-ear lesion is in other locations. 
Nevertheless, it may be said that a certain number of perforations in the 
region of the short process of the malleus may be of congenital origin, 
and that this portion of the membrana tympani is thereby rendered more 
vulnerable. 



INJURIES OF THE MEMBRANA TYMPANI 

While injuries to the membrana tympani are comparatively rare, 
nevertheless, when they do occur it is important to know the proper 
method of procedure. They may be due to either direct or indirect 
violence. 

Etiology. — Injuries by direct violence may be due to (a), attempts to 
remove the cerumen from the meatus with a pin, a hairpin, a toothpick, 
an earspoon, etc. ; (b) the accidental thrust of any long slender instru- 
ment, tool, or splinter of wood; (c) the introduction of a caustic or a hot 
fluid into the meatus; (d) the fracture of the bone which supports the 
membrana tympani; (e) and finally, sneezing, inflation of the ear, etc., 
may also rupture the membrana tympani. 

Injuries by indirect violence may be due to (a) the violent and sudden 
compression of air in the meatus by a blow on the ear with the palm of the 
hand, or it may be due to (b) the concussion of the atmosphere during a 
violent explosion or discharge from a large cannon. In view of the more 
or less familiar occurrence of windows being blown outward at the time 
of an explosion, it may be readily appreciated how the membrana 
tympani may be ruptured by such an atmospheric disturbance. 

(669) 



670 THE EAR 

Symptoms. — Pain is a prominent symptom in those cases in which 
there is severe reactionary inflammation, while it may be absent if 
little or no inflammation follows the injury. In some cases the pain is 
only present at the time of injury. Hemorrhage, more or less severe, 
may immediately follow the injury, or in rare cases it may continue for 
an indefinite period. Faintness, giddiness, nystagmus, staggering gait, 
convulsions, and nausea characterize those cases in which the foot plate 
of the stirrup is forced inward, and in which the trauma irritates or 
otherwise injures the labyrinth. The loss of hearing may be partial or 
complete and temporary or permanent. The tinnitus at first comes on 
as a loud noise, and then subsides until it is only moderate in severity 
or entirely ceases. The effects upon the hearing are various. Deafness 
may be so great that the watch can only be heard by contact, or, on the 
contrary, the patient may suffer from hyperesthesia acoustica. When 
the labyrinth is injured, the deafness may be great or absolute. If the 
injury involves the semicircular canals, the equilibrium may be dis- 
turbed for a few days or weeks. 

If the injury occurs in an ear in which the drumhead is adherent to 
the promontory, it may overcome the adhesions and thus affect the 
hearing favorably. In some cases the orientation for sounds is lost, 
while in others there is simply a sense of fulness in the ears. 

The rupture is usually located in the postinferior quadrant of the 
membrana tympani, the periphery not usually being involved, as the 
membrane is thicker and firmer near its border. The appearance of the 
rupture is usually a mere slit (dark line), which varies in extent and shape. 
In other cases, it may appear as a round perforation with ecchymotic 
spots scattered over the membrane. If the injury were inflicted by a blunt 
instrument, the perforation is irregular or ragged in outline. 

Cases have been reported in which there was an escape of cerebro- 
spinal fluid from the ear, a foreign body having entered the labyrinth. 
The fluid may also escape into the middle ear when there is a fracture 
through the petrous portion of the temporal bone. 

The ossicles of the middle ear, more particularly the malleus, are 
sometimes fractured. While the fractured parts reunite, they do not 
usually do so in their normal position. The author once saw a case 
in which the handle of the malleus was fractured about 1 mm. below 
in short process and the parts reunited in nearly or quite their normal 
position. 

Prognosis. — The prognosis is usually good, as the injury ordinarily 
consists of a simple laceration or perforation of the membrane. In those 
cases in which the labyrinth is involved the prognosis should be guarded. 
If the injury to the labyrinth consists of a perforation of its outer wall, 
good result may be expected after the lapse of a few weeks. The giddi- 
ness and nausea may persist for one or more weeks. If the osseous walls 
of the middle ear are fractured, or if the ossicles are injured, the hearing 
may be permanently impaired. Should purulent inflammation compli- 
cate the case, the prognosis becomes more grave. The functional tests of 
hearing should be used in all cases of fracture or injury, as by them the 



MYRINGITIS 671 

surgeon is enabled to draw conclusions as to the extent and location of 
the injury and as to the probable outcome of the case. 

Treatment. — In nearly all cases no treatment should be used other 
than the introduction of a cotton or gauze tampon into the meatus to 
prevent the entrance of infectious matter through the wound. If, in 
spite of this simple precaution, marked inflammatory symptoms develop, 
leeches should be freely applied over the mastoid region and in front of 
the tragus, to promote the reaction of inflammation and thus aid in des- 
troying the bacteria. Great care should be exercised in the treatment of 
these cases lest infection be carried into the wound and the case become 
complicated by suppurative inflammation of the middle ear and mastoid 
cells; hence, meddlesome treatment is to be condemned. 

MYRINGITIS; INFLAMMATION OF THE MEMBRANA TYMPANI 

Etiology. — Myringitis may be primary or secondary. The primary 
form is rare, and when present it is usually due to an injury by a foreign 
body, instrumentation, or the introduction of caustic fluids into the 
meatus. Secondary inflammation of the membrana tympani is more 
common, and is due to an extension of an inflammatory process from the 
auditory meatus or the cavum tympani. Thus, in the various forms of 
dermatitis and acute otitis media catarrhalis it is often present. 

Symptoms. — The chief symptoms are pain, more or less severe in 
character, with a slight rise in temperature. Deafness and tinnitus are 
present in proportion to the local injury, the swelling of the membrana 
tympani, and the nature of the associated middle-ear disease. 

Objective Symptoms. — The membrana tympani is usually most affected 
in its upper portion and especially along the line of the handle of the 
malleus. In this region it is yellowish red in color, from the congestion 
present. In a few days or hours, the handle is lost to view, owing to 
the intense congestion and infiltration of the membrane, the upper 
portion of which bulges outward into the canal. The epidermic layer 
may become separated from the fibrous or middle layer of the ear drum 
by the serous or seropurulent fluid which accumulates between them. 
Blisters or blebs sometimes form. The inflammatory process may involve 
the osseous portion of the canal and thus obliterate the line of demar- 
cation between the eardrum and the canal. 

The mode of termination is by slow resolution, and the signs of inflam- 
mation often persist for many weeks. In some cases fatty degeneration 
or even calcareous deposits may remain after the disease is cured. 

Abscess of the membrana tympani may occur in the course of acute 
otitis media. The process is confined chiefly to the fibrous and the 
mucous membrane layers, in contradistinction to the blisters which 
form under the dermic or outer layer. 

Vesicular or herpetic eruptions sometimes complicate myringitis, as 
referred to above. 

Hemorrhagic eruptions similar to those described under Otitis Externa 
Hemorrhagica are occasionally present, 



672 THE EAR 

Diagnosis. — The chief diagnostic point to be found is the slight 
disturbance of hearing. The ear appears to be extensively and seriously 
involved, while the hearing is but slightly impaired. The appearance 
is much like that of acute suppurative otitis media, but the loss of hear- 
ing is slight as compared with that which occurs in the latter disease. 

Prognosis. — The prognosis must be based upon a knowledge of the 
etiology of each case and upon the destructive or degenerative changes 
which occur in the membrana tympani. If the myringitis is due to a 
severe injury, or if fatty degeneration and calcareous deposits are in the 
substances of the membrana tympani, the prognosis is less favorable than 
when the case is simple in origin and of slight severity. On the other 
hand, if perforation takes place and chronic suppurative otitis media 
supervenes, the prognosis is still more unfavorable. 

Treatment. — The treatment is (a) general, (b) local, and (c) surgical. 
The general treatment should consist in the administration of tonics, 
the iodides, and cod-liver oil if the patient is subject to any dyscrasia; 
saline cathartics should also be administered. The local treatment 
should consist of the application of natural or artificial leeches to the 
mastoid process, to increase the hyperemia and leukocytosis, i. e., promote 
the reaction of inflammation. The instillation of solutions of cocaine 
are advised, but are of doubtful utility unless used in the following 
combination: 

1$. — Cocaine hydrochloratis, 
Menthol crystals, 

Carbolic acid crystals aa 3j — M. 

Sig. — One or two drops in the fundus of the auditory meatus will relieve the pain in from 
five to fifteen minutes. 



The parts are at the same time anesthetized and prepared for the 
opening of the abscess in the membrana tympani if it is present. The 
remedy should be used with some caution, as it is likely to be absorbed 
in sufficient quantity to cause toxic symptoms. The instillation of alcohol 
into the meatus dilutes the solution and facilitates its removal if it should 
become necessary. 

The surgical treatment should consist in the incision of the outer or 
dermic layer of the membrana tympani. In cases which are complicated 
by abscess, care should be exercised to avoid perforating the inner layer, 
as infection might thus be carried to the middle ear. Gruber recom- 
mends making incisions in the osseous portions of the auditory meatus 
near the membrana tympani. The incisions should be about J inch long 
and parallel with the circumference of the drumhead, so as to incise 
the arterial branches at its circumference. The incisions promote the 
reaction of inflammation and favor resolution. 

After the abatement of the acute stage a serous discharge is given 
off from the membrana tympani and the painful symptoms subside. 
The ear should now be irrigated with a warm boric acid solution, dried, 
and the meatus closed with absorbent cotton. 

The cavum tympani (middle ear) may be inflated by the Politzer 



PERFORATION OF THE MEMBRANI TYMPANI 673 

method; the diagnostic tube should be used to determine if a perforation 
is present. The membrana tympani should also be inspected for the 
same purpose. If a perforation is present, the diagnostic tube conveys 
to the examiner's ear the whistling sound characteristic of a perforation. 
The membrana tympani may be so swollen that the perforation can- 
not be seen. The discharge of pus into the meatus is another indication 
of the presence of a perforation. This is rendered all the more prob- 
able if the discharge contains strings of mucus. The presence of a per- 
foration and chronic otitis media render the prognosis more serious. 



PERFORATION OF THE MEMBRANA TYMPANI; ULCERATION OF 
THE DERMIC LAYER; CHRONIC MYRINGITIS; CHRONIC 
INFLAMMATION OF THE DRUMHEAD 

Etiology. — The causes leading to perforation of the membrana tympani 
may be either external or internal. One of the external causes is acute 
myringitis, with local fatty degeneration and subsequent sloughing of the 
substance of the drumhead, the degenerative process beginning with the 
outer layer and extending inward. Another external source is acute 
dermatitis of the external meatus. This may extend to the drumhead and 
result in the same degenerative and perforative processes. In many 
instances the fatty degeneration is not followed by perforation, but 
calcareous changes occur instead. 

In some cases the destructive process is limited to a simple ulceration 
of the dermic layer, which may appear as a simple circumscribed rough- 
ness of the surface or as a reddened area where the epidermis is removed. 

The internal causes of perforation or chronic inflammation are either 
the acute catarrhal or the acute suppurative forms of otitis media. The 
mucous layer of the drumhead first undergoes the ulcerative process, 
and the fibrous and dermic layers are involved at subsequent periods. 
The membrana tympani may long remain the seat of chronic inflamma- 
tion, because the bloodvessels are injected and radiate from the margins 
of the ulceration or perforation. 

Symptoms. — If the lesion is simple— a superficial dermic ulcer — the 
symptoms are slight, and tinnitus and a moderate disturbance of hearing 
are present. If the ulcer is phlegmonous in type, pain and increased 
deafness result. The secretions and the exfoliation of epidermis form 
crusts on the surface of the membrana tympani, which obscure the 
real lesion. Granulations may spring from the bottom of the ulcer. 

In those cases in which there is perforation, the tinnitus and the deaf- 
ness are great. If the middle-ear cavity is not primarily infected, it 
becomes so through the perforation. Pus is discharged through the 
opening into the external auditory meatus. If the ear is inflated by 
the Valsalva, the Politzer, or the catheter method, a whistling noise 
may be heard through the diagnostic tube. Inspection, after removal 
of the debris from the auditory meatus, usually reveals the perforation. 
It is often oval, though it may be round, pear- or kidney-shaped. Its 
43 



674 THE EAR 

location generally indicates the focal centre involved within the middle 
ear or the accessory mastoid cavities. 

Course. — The duration of chronic inflammation of the membrana 
tympani, with or without perforation, is usually quite prolonged. The 
dermic layer often undergoes repeated or continuous desquamation, or 
there may be foci of fatty degeneration with calcareous deposits. In 
some cases there is an atrophic process which renders the membrane 
thin and parchment-like, and its function is thereby impaired. In still 
other cases of external origin perforation occurs, and is followed by infec- 
tion and suppuration within the middle ear. This may continue indefi- 
nitely, or until ulceration and necrosis of the bony walls of the middle 
ear and the pneumatic spaces of the mastoid process occur. 

Treatment. — In those cases in which there is an active desquamation 
or dermic ulceration, the crusts should be softened with a warm sohition 
of bicarbonate of soda, and then removed by syringing with a warm 
solution of boric acid. The author's experience has justified the local 
application of 10 gr. solution of the nitrate of silver or of the compound 
tincture of benzoin. The nitrate of silver stimulates healthy granulation 
and regeneration, and the compound tincture of benzoin is astringent 
and stimulates the process of repair. 

If perforation has taken place and the cavum tympani is not yet 
infected, an endeavor should be made to bring about regeneration of the 
membrana tympani, and thus close the perforation. This may be done 
by maintaining the external auditory meatus and the membrana tympani 
in an aseptic condition, and by making stimulating applications to the 
margins of the perforations, with the view of promoting granulation 
until the opening is completely filled in. Various drugs and procedures 
have been employed for this purpose, the best one being the local appli- 
cation of a 20 per cent, solution of trichloracetic acid. 

For the treatment of the middle ear complications see Suppurative 
Diseases of the Middle Ear. 



INCISION OF THE MEMBRANA TYMPANI 

This method of treatment is coming into vogue more than formerly, as 
clinical experience has demonstrated that when it is done at the proper 
time an acute inflammation of the middle ear is aborted. Its effects 
are due to the promotion of the reaction of inflammation and the facility 
with which the drainage of the tympanic cavity is accomplished. The 
presence of the inflammatory exudate within the cavum tympani is a 
source of irritation because of its chemical composition and on account 
of the pressure it exerts upon the swollen and inflamed mucous membrane. 
It is, therefore, important that free drainage be established at a very 
early period in the course of the disease. Formerly, it was recommended 
that simple puncture of the drumhead be made for this purpose. Hovell 
advocates this procedure. The author's experience, however, has shown 
that such an incision is too small and that a free incision is attended by 



INCISION OF THE MEMBRANA TYMPANI 



675 



Fig. 392 



immediate and better results. No harm comes from free incision of the 
membrana tympani, as union often takes place before it is desirable. 
Even when union does not occur early, only a very slight amount of scar 
tissue is left behind. 

The operation should not be delayed until there is bulging of the 
membrana tympani, but should be undertaken as soon as there is marked 
redness and thickening. If the incision is de- 
layed, the membrana tympani may be so swollen 
and red that the outline of the malleus cannot 
be distinguished, and bulging of the drumhead 
may occur, resulting in serious and extensive 
pathological changes. If it is done early, the 
progress of the disease is checked and the pro- 
cess of resolution is established. The incision 
increases the hyperemia and leukocytosis, and 
thus raises the resistance of the tissue and 
destroys the microorganisms. 

The most suitable place for the incision is 
in the posterior inferior quadrant (Fig. 392), 
as this is generally the most accessible, owing to 
the curvature of the anterior wall of the external 
auditory meatus, which obstructs the view of 
the anterior portion of the membrana tympani. 

The best instrument for the purpose is a curved bistoury (Fig. 393). 
The lance-shaped or the pear-shaped knives are not well adapted, as 
they are made for simple paracentesis. The point of the knife should 
be introduced only far enough to penetrate the thickness of the membrana 




Ri^ht membrana tympani, 
showing the division into A, 
postsuperior quadrant; B, 
anterosuperior quadrant; C, 
antero-inferior quadrant; D, 
postinferior quadrant. 



Fig. 393 




Ear instruments. 



tympani, as to pass it deeper might subject the inner wall of the cavum 
tympani to injury. It should be remembered that the distance from the 
outer to the inner wall is only about iV to 6 inch. The incision should be 
curved or V-shaped (Fig. 394), to allow a wider opening between the 
lips of the incision, and should be from \ to | inch in length. In this 
way free drainage is established. 

Immediately after the incision a bead of viscid mucus may be seen 



676 



THE EAR 



Fig. 394 




protruding through it. The contents of the tympanic cavity are not 
discharged at once unless they are of a fluid nature, and to hasten this 
discharge, a solution of boric acid or bicarbonate of soda may be dropped 
into the meatus to liquefy it. 

Previous to the incision the external auditory meatus should be cleansed 
with a 1 to 4000 solution of bichloride of mercury to render the mem- 
brana tympani and the auditory meatus sterile. Anesthesia of the 
membrana tympani may be obtained by dropping a small quantity of a 
solution composed of ec^ual parts by hydrochlorate of cocaine, menthol, 
and carbolic acid into the auditory meatus. In from five to fifteen 
minutes complete anesthesia is produced, and the incision may be made 
with comparatively little or no pain. Complete absence of pain is not 
always obtained, however, as it should be re- 
membered that the parts contiguous to the 
membrana tympani are often inflamed and 
sensitive. 

Immediately after the incision the auditory 
meatus should be dried with a cotton-wound 
applicator and then loosely packed with steril- 
ized gauze. The end of the strip of gauze 
should be made to touch the incised portion of 
the drumhead, while the rest is placed loosely 
in the meatus. It should be left in place until 
it becomes saturated with the secretions, when 
it should be removed and a fresh one intro- 
duced. During the first two or three days it 
may be necessary to pack the meatus two or 
more times a day. The patient should be 
kept in bed during this time, as much more 
favorable and rapid progress may be made 
under such conditions. After the first few days 
it is not necessary to dress the meatus so often, 
once a day being quite sufficient. A little 
later every other day will be all that is neces- 
sary. The dressings should be discontinued when the discharge through 
the incision ceases. 

After the incision is made, all applications of solutions by means of 
the syringe are to be stopped, as infection may thereby be conveyed 
through the opening into the tympanic cavity. When the acute inflam- 
mation has somewhat subsided, inflation by the Politzer method through 
the Eustachian catheter should be performed to facilitate drainage. 

Spontaneous perforation of the drumhead may take place in the course 
of the disease from softening of the tissues by maceration or from press- 
ure necrosis. As already stated, this should be anticipated, if possible, 
either by instrumental perforation of the drumhead or by one or more 
of the remedies which have been recommended. Should spontaneous 
perforation occur the treatment should be similar to that recommended 
after incision of the membrana tympani. 



Showing a long, curved in- 
cision through the membrana 
tympani for the evacuation of 
inflammatory secretions. With 
such an incision the anterior 
flap is forced aside by the 
secretions as indicated by the 
dotted line, thus providing 
free space for drainage. A 
simple puncture or paracen- 
tesis as shown by the short 
line is inadequate and should 
not be practised. 



INCISION OF THE MEMBRANA TYMPANI 677 

Paracentesis is an almost obsolete form of incision, and is not given as 
synonymous with incision. The latter means a larger and more extensive 
opening in the drumhead than is implied by the former. By paracentesis 
is meant a mere puncture through the membrane with a double-edged 
or spear-pointed knife. What follows, therefore, refers to some form 
of incision and not to a mere puncture of the drumhead. 

The general purposes of incision of the membrana tympani are: (a) To 
relieve pain; (b) to establish drainage for excessive secretions (catarrhal 
and suppurative); (c) to open the middle ear for certain operations; 
(d) to relieve intralabyrinthine pressure; (e) to allow sound waves to 
reach the oval and round windows; and (/) to promote the reaction of 
inflammation. 

The indications for incision, as briefly outlined in the preceding para- 
graphs, may be amplified as follows: 

1. In otitis media with excessive secretion, it may become necessary 
to m^ke a free incision to prevent pressure necrosis of the drumhead and 
the tympanic mucosa. The secretion is often so thick and tenacious that 
it will not discharge through the Eustachian tube. Retention also causes 
pain, and there is danger of decomposition and infection. The incision 
also promotes the reaction of inflammation, and thus favors speedy 
resolution. 

The operation should not be delayed until pronounced pain develops, 
bulging of the membrane being ample justification for the procedure. 
Should pain persist without bulging, the incision should be made, as it 
promotes the reaction of inflammation and thus favors resolution. 

2. In acute myringitis abscess formations may occur between the 
layers of the membrana tympani. They should be opened, care being 
taken not to cut the inner or mucous layer which would expose the 
middle ear to the dangers of infection from the abscess. 

Pearly gray blisters sometimes appear on the membrana tympani. 
These should be pricked, for if left to discharge spontaneously they 
prolong the danger of infection. 

Inflammation of the deeper layers with bulging and purplish swelling 
should be scarified to relieve the pain and tension. Incisions through the 
entire thickness should not be attempted, for the reasons already stated. 

3. Tenotomy of the tensor tympani muscle is sometimes performed 
to relieve deafness and tinnitus. (See Tenotomy of the Tensor Tympani 
Muscle.) The preliminary step in the operation is an incision of the 
membrana tympani. 

4. In chronic catarrhal otitis media, a thickened membrana tympani 
from hyperplasia with obstruction of the Eustachian tube is often present. 
The rarefaction of the air within the tympanum causes the retraction 
of the membrana tympani and pressure upon the labyrinthine fluid 
by the foot plate of the stapes. The drumhead may be incised as a 
temporary measure, or a portion of the drumhead may be removed with 
a knife or cautery to admit air into the middle ear when the Eustachian 
tube is obstructed. All such measures have met with but partial or 
temporary success, the opening usually closing within a few days. 



678 THE EAR 

The relief is often pronounced while the perforation remains open, 
but quickly disappears after it closes. 

Malherbe has written extensively upon what he terms "Evidement of 
the Mastoid/' whereby a channel of communication between the tym- 
panic antrum and the external acoustic meatus is established, as in the 
meatomastoid operation, which permanently overcomes the disturbance 
due to the closure of the Eustachian tube. 

5. In acute catarrhal otitis media, attended with pain, bulging, and 
marked inflammatory infiltration, incision or scarification is often indi- 
cated to promote the reaction of inflammation and to establish drainage. 
If there is persistent pain, with or without bulging of the membrana 
tympani, incision is indicated. The relief which follows may be due 
to the hemorrhage, for in many cases there is no discharge of secretions 
for several hours, though it is more probably due to the promotion of 
the reaction of inflammation. 

When there is a livid, boggy appearance of the membrane, it should be 
freely scarified, limiting the incisions to the outer layer. Circumscribed 
red spots sometimes appear in the course of the disease, which should be 
opened to hasten the process of resolution. 

The most bulging portion of the membrana tympani may appear 
yellowish green in color, even though there is little pus in the secretion. 
Free incision should be made to establish drainage and to relieve the 
pressure necrosis which is beginning on the inner surface of the mem- 
brana tympani. 

6. Acute suppurative otitis media affords the most common opportu- 
nity for incision of the membrana tympani, although it is often postponed 
until voluntary rupture occurs. The presence of pus within the middle- 
ear cavity when the drumhead is still intact is an imperative indication 
for incision. It is not necessary to wait for pain and bulging of the mem- 
brana tympani; in fact, it is culpable negligence to do so, as every hour 
adds to the destruction of tissue. Incise the membrana tympani at once 
when the presence of pus is suspected in the middle ear, as it is of the 
greatest importance to promote the reaction of inflammation to combat 
the bacteria and their toxins. 

The perforation in acute suppuration is usually small, hence it should 
often be enlarged by radiating incisions toward the periphery (Fig. 395). 

Persistent pain without bulging or profuse discharge of pus is an 
indication of retained pus within the antrum and mastoid cells. The 
incision in these cases should include the pars flaccida (Shrapnell's 
membrane), to afford a direct cutlet from the attic and to increase the 
reaction of inflammation. 

7. Adhesive processes in the middle ear sometimes gives rise to condi- 
tions which can be more or less relieved by incising the membrana tym- 
pani. The adhesive process may interfere with the vibratory action of 
the ossicles without the foot plate of the stapes being ankylosed. The 
opening in the drumhead admits sound waves into the tympanum where 
they strike the foot plate of the stapes, and fairly good hearing results. 
The tinnitus which is associated with the deafness is also relieved to some 



INCISION OF THE MEM BRAN A TYMPANI 679 

extent. As it is not practicable to maintain the opening for any con- 
siderable length of time, the procedure has almost fallen into disuse. 

Calcareous deposits in the membrana tympani are often found associ- 
ated with adhesive processes. They act as foreign bodies and impair 
the vibratory function of the membrana tympani, and an opening, as 
above stated, admits sound waves directly to the oval window. More- 
over, the equilibrium of air pressure is thereby established and the 
pressure on the labyrinth by the ossicles is somewhat lessened. 

Through the opening it is sometimes possible to sever adhesive bands 
which extend from the malleus and incus to the walls of the tympanum. 
AYhile the beneficial effects thus obtained are not permanent, tem- 
porary relief is marked and extremely gratifying to the patient. They 
are much depressed in spirits, and the temporary respite adds to their 
happiness. It should be frankly explained that the beneficial result will 
in all probability not be permanent. 

Fig. 395 




Showing two perforations of the membrana tympani and the incisions for facilitating drainage 
through them. The incisions should extend at an angle to the axis of the perforation so as to form 
movable flaps which may be pushed aside by the secretions. 

8. Atrophy and relaxation of the membrana tympani from too fre- 
quent inflation or other causes may be improved by light scarification 
with a sharp-pointed bistoury. Only the outer and the middle layer 
should be cut through. In this way the scar tissue and blood supply will 
be increased, and the tension and tone of the membrane raised, with 
benefit to the hearing. 

9. Exploration of the middle ear and the attic sometimes becomes 
necessary in chronic suppuration. This is best done when the opening 
in the membrana tympani is high, as the roof or tegmen is usually 
necrosed. If, therefore, the perforation is small or in the lower portion 
of the drumhead, it may be necessary to extend it by incision in an 
upward direction. This operation allows a small curved ear probe to be 
introduced into the attic for exploratory purposes. 

Preliminary examination of the function of hearing should be made 
before incising or removing a portion of the drumhead to improve hearing 
in adhesive processes of the middle ear. Unless bone conduction for 
the watch and the c 2 , 512 v., fork is good, but slight improvement will 
follow the operation. Lowered bone conduction is usually significant of 



680 THE EAR 

labyrinthine disease, hence incision of the membrana tympani will be 
of no value. 

The middle and the lower portion of the posterior half of the membrana 
tympani is less sensitive than the upper portion, the sensitiveness gradu- 
ally increasing as the upper limit is approached. Blake takes advantage 
of this fact and punctures the membrane in its least sensitive area, then 
applies cocaine to the cut surfaces, waits a few minutes, and extends the 
incision slightly upward, applies more cocaine, and so continues until 
the incision is extended the desired length. 

He also recommends the injection of a 2 per cent, solution of cocaine 
through the Eustachian catheter into the middle ear, as a means of pro- 
ducing anesthesia of the membrana tympani in middle-ear operations. 

Dupuy recommends the following mixture as a reliable local anesthetic 
in eardrum and middle-ear operations: 

1$. — Aniline oil, 

Alcohol aa 5j 

Cocaine hydrochlorate gr. vj — M. 

Sig. — Drop into the meatus and middle ear. 

This mixture does not always produce local anesthesia. In a number 
of the author's cases it has failed, notably in aural polypi. 

More or less cyanosis occasionally attends its use, hence it should be 
applied with caution. 

The following mixture is more reliable and less dangerous: 

1$. — Cocaine hydrochlorate, 

Menthol crystals. 

Carbolic acid crystals aa 5J — M. 

Sig. — Drop into the meatus or middle ear, and in twenty minutes anesthesia is complete. 

The absorption is greatly facilitated by first macerating the drum- 
head with the peroxide of hydrogen. 

Methods of Operating. — The electrocautery may be used in adhesive 
non-inflammatory cases. The opening thus made remains longer than 
one made with a knife. The points to be observed are the following: 

(a) Preliminary local anesthesia should be produced by the injection 
of the above formula or a 2 per cent, solution of cocaine into the middle 
ear through a Eustachian catheter. 

(b) The electrode should be a simple straight, pointed one with the 
shank so bent that the electrode handle and the hand of the operator 
do not obstruct the view. 

(c) The current should be sufficient to instantly raise the point to 
a bright-red heat. If the platinum point heats too slowly the adjacent 
parts may be injured by the radiation of heat. The pressure exerted by 
the electrode should be slight to avoid the danger of injuring the mucous 
membrane of the inner tympanic wall. 

(d) Contact should be made with the drumhead before the electric 
current is turned on. 

(e) Usual time of heat contact, one second. 



INCISION OF THE MEMBRANA TYMPANI 



681 



Incision with a Lancet. — Preference should be given to Hartman's 
curved lancet, the spear-pointed instruments formerly used being of 
little value except for simple puncture. 

The most favorable or available location for incision in adults is the 
posterior half of the drumhead (Fig. 392). In children the external 
meatus is shallow and straight, so that all portions of the drumhead are 
accessible. 

Fig. 396 Fig. 397 





Showing a long, curved incision of the mem- 
brana tympani extending into the superior wall 
of the meatus (white line). As there is a 
plexus of bloodvessels around the margin of 
the membrana tympani, greater reaction of 
inflammation is produced by extending the 
incision through it, hence the improvement of 
the inflammation is more prompt than in simple 
incision of the membrane. (See Reaction of 
Inflammation.) 



Fig 



Incision for stapedectomy, showing the incu- 
dostapedial articulation. The stapedius muscle 
should be severed to prevent the dislocation of 
the stapes, the incudostapedial articulation 
broken, and the stapes removed from the oval 
window. This operation is rarely justifiable. 




Showing an incision through the posterior fold of the membrana tympani to relieve the 
tension of the membrane in adhesive processes. 



Other things being equal, the most bulging portion (fluid being present) 
should be incised, because it is the point of least resistance and because 
the parts are not so sensitive in this area. If the bulging is pronounced, 
the incision can often be made without the use of a local anesthetic. 

The length, direction, and character of the incision should depend upon 
the purpose for which it is made. If it is done to establish /m? drainage, 
it should be long and curved, or angular (Fig. 396). If it is to expose the 
contents of the middle ear, as for operations upon adhesive bands and 
upon the stapes, the V-incision recommended by Blake (Fig. 397) should 



682 THE EAR 

be made. If it is for the purpose of admitting air to the middle ear, a 
round or triangular opening may be made. The cautery is well adapted 
for this purpose. If it is done preliminary to tenotomy of the tendon of 
the tensor tympani, or for plicotomy, a short, straight incision (Fig. 398) 
is all that is necessary. 

Postoperative Considerations. — (a) When the incision is made to 
evacuate mucus or mucopus, a pulsation synchronous with swallowing 
and articulation will occur at the point of incision. Pus and mucus 
rarely appear immediately after the incision. This is quite disconcerting 
to the inexperienced aurist, as he may have unwittingly promised an 
immediate evacuation of the secretions. A little experience, however, will 
teach him that on account of the thick and adhesive character of the 
secretions, they will usually require several hours to appear. The ex- 
pulsion of the secretions can be hastened by instilling a warm solution 
of bicarbonate of soda into the middle ear. The soda overcomes the 
adhesive property of the mucus and facilitates its discharge. Some- 
times the mucus is so thick and tenacious that it can be seized with 
forceps and removed. It may also be removed by suction with the 
Delstanche masseur. 

(b) Closure of the incision in non-suppurative cases usually occurs in 
from one to three days. In suppurative cases it may remain open a few 
days or indefinitely. 

(c) The dressing should consist of a strip of sterilized gauze placed 
loosely in the meatus, but touching the drumhead. If the discharge is 
profuse, a pad of gauze may be placed over the auricle and held in 
position by a bandage. The meatus and the auricle should first be 
cleansed with a 1 to 3000 bichloride solution before introducing the 
gauze dressings. 



CHAPTEE XXXIX 

DISEASES OF THE EUSTACHIAN TUBES 

THE RELATIONSHIP OF THE EUSTACHIAN TUBES TO HEARING 
AND MIDDLE-EAR DISEASES 

The Eustachian tube is the chief source of communication between 
the epipharynx and the middle ear. Through it the tympanic cavity 
is ventilated and the normal tension of the drumhead and the ossicular 
chain is maintained, thereby facilitating the transmission of sound 
waves to the internal ear. The pharyngeal end of the tube is supported 
by cartilage, while the tympanic end has an osseous framework. At 
the union of the cartilaginous and the osseous portions the tube becomes 
narrow, forming what is known as the isthmus. The throat end is 
subject to the diseased processes peculiar to the epipharynx, while the 
tympanic end is affected by the changes peculiar to the tympanic cavity. 
In other words, the throat end is subject to pronounced catarrhal and 
suppurative inflammations and to hypertrophy of the lymphoid tissue in 
its mucous membrane, and the tympanic end to catarrhal and adhesive 
changes in addition to the suppurative process. The adhesive process 
is, therefore, chiefly found in the less accessible portion of the tube — 
namely, beyond the isthmus, and consequently difficult to reach with 
electrolytic bougies, or those used for the purposes of simple dila- 
tation. 

The relationship of the Eustachian tube to the diseases of the tympanic 
cavity is twofold, namely: (a) Obstruction of its lumen by catarrhal 
congestion, hypertrophy, cicatricial contraction, and mucous plugs; and 
(b) as an avenue through which infective material may gain entrance 
to the middle ear. The obstructive lesions or accumulations prevent the 
proper ventilation of the tympanic cavity, and the contained air becomes 
rarefied through the gradual absorption of the oxygen, thus causing 
retraction of the drum membrane and engorgement of the bloodvessels 
of the mucous membrane. 

The retraction of the drumhead increases the tension of the ossicular 
chain, and interferes with the normal transmission of sound waves to 
the labyrinth. Tinnitus and deafness thus result. The obstruction to 
drainage lowers the resistance of the tissues and predisposes to infection 
and inflammation. 

Infectious material may gain entrance into the middle ear during 
acts of yawning, coughing, sneezing, or swallowing. The tube is lined 
with ciliated columnar epithelium, having a wave-like motion toward 
the pharyngeal orifice. In the healthy state bacteria rarely travel toward 

(683) 



684 THE EAR 

the middle ear on the mucosa. If, however, the catarrhal inflammation 
of the lining membrane of the tube is severe or prolonged, the epithelium 
may lose its cilia, and allow germs to reach the middle ear without the 
tube being opened by the acts of coughing and sneezing. 

Tubal tonsils, or hypertrophy of the lymphoid tissue in the mucous 
membrane of the cartilaginous portion of the tube, is another possible 
source of obstruction. A study of the histology of this structure shows 
lymphoid tissue to be present in considerable quantity, and it is more 
than probable that hypertrophy of this tissue is often responsible for 
tubal and middle-ear disturbances heretofore ascribed to catarrhal or 
other diseases. 



TUBAL CATARRH; CATARRHAL INFLAMMATION OF THE 
EUSTACHIAN TUBE; SALPINGITIS 

Etiology. — Owing to the intimate anatomical connection of the 
mucous membrane of the Eustachian tubes with that of the epipharynx, 
it is easy to understand why they are usually involved in the course 
of an attack of epipharyngeal inflammation. If the epipharyngitis is 
chronic in character, the tubal disease is likewise chronic. While tubal 
catarrh is usually secondary to a like process in the epipharynx, it is 
not always so, especially in children. In young children the pharyngeal 
orifice is narrow and is easily obstructed by the secretion and foreign 
matter. For this reason local inflammation may occur in the tubes 
independent of the epipharynx. 

Adenoid growths are often associated with a chronic epipharyngitis, 
which extends by continuity to tissue of the tubes. The adenoids do 
not often afford a mechanical obstruction to the patency of the tubes, 
as they grow from the posterior and superior walls of the epipharynx, 
and, therefore, do not involve the regions of the Eustachian orifices on 
the lateral walls. In some instances, however, they overlap the mouths 
of the tubes and thus obstruct them. Tuberculosis may be associated 
with adenoid growths and predispose to tubal inflammation. 

Thomas H. Brunk first, and later W. S. Bryant, called attention to 
the presence of granulation tissue and adhesive bands in Rosenmiiller's 
fossae, claiming that their removal with the finger introduced through 
the mouth, or with a straight curette through the nose, relieved tubal 
catarrh and deafness. Indeed, this opinion is attracting considerable 
attention, as the removal of these bands have in numerous cases been 
followed by great improvement. The adhesive bands are frequently 
present and should be searched for more frequently than has been 
customary. 

Pathology. — Congestion and round-cell infiltration characterize the 
early and acute stages of the disease. At a later period the epithelial 
covering becomes thickened, and fibrous tissue is deposited in the 
subepithelial layers. Hypertrophy of the mucous membrane occurs 
when the inflammation continues for a long time. If the inflammation 



TUBAL CATARRH 685 

is severe or prolonged, the cilia are exfoliated, leaving the membrane 
denuded in places. The catarrhal inflammation may extend to the 
middle ear, although it has a tendency to limit itself to the pharyngeal 
or cartilaginous portion of the tube. 

Symptoms. — The subjective symptoms are a feeling of fulness in 
the ears, which may be constant or intermittent, accompanied by sub- 
jective noises and deafness. Pain is not usually severe, although it 
may be if the inflammation is pronounced. If there is marked retraction 
of the drumhead, giddiness and nausea may be complained of. The 
sense of deafness is often out of proportion to the actual deafness. The 
patients apply for relief with the statement that the external canal is 
filled with cerumen. During mastication and swallowing, they often 
experience marked, though brief, relief from the symptoms. This is 
explained by the incidental, but incomplete, ventilation of the tympanum 
during the act of swallowing. Upon "posterior rhinoscopy, the mucous 
membrane of the epipharynx and the Eustachian orifices appears red- 
dened, swollen, and covered with a thick mucous secretion. The mouths 
of the tubes are contracted by the swollen membrane, and may contain 
a thick, tenacious mass of mucus. If adenoids are present, the furrows 
between the lobules are more or less filled with a slimy secretion admixed 
with pus. The ethmoidal and sphenoidal sinuses may also be the seat 
of inflammation. With good illumination it is possible to see the enlarged 
and tortuous bloodvessels in the inflamed area. 

The drumhead is more or less changed in its position and appearance 
by the rarefaction of the air in the tympanic cavity. It is more cupped, 
the handle of the malleus is foreshortened, and the short process and the 
posterior fold extending from it are more prominent. The angle formed 
by the handle of the malleus and the posterior fold becomes more acute 
with the increased retraction. The cone of light is diminished, broken, 
or altogether wanting. If the drumhead is extremely retracted, the 
promontory and the long process of the incus become visible through it. 

Prognosis. — The prognosis is good in those cases in which adenoid 
growths are removed, especially in children. It is also good in the early, 
or congested stage of the simple catarrhal type in adults. In the hyper- 
trophic stage it is not good, as the obstruction is more permanent in 
character. If the obstruction is due to lymphoid hypertrophy in the 
pharyngeal end of the tube, the prognosis is not good, although the 
removal of the adenoids reduces the congestion and improves the deaf- 
ness. If the obstruction is due to adhesive bands in Rosenmiiller's 
fossa the prognosis is good if the bands are removed. 

Treatment. — The treatment of tubal catarrh should be largely 
addressed to the antecedent nasal and epipharyngeal conditions. If 
there is pronounced nasal catarrh, sinuitis, nasal obstruction, or epi- 
pharyngitis, appropriate treatment should be undertaken, and the aden- 
oids should be removed. Removal of the adenoids is usually followed by 
pronounced and immediate relief. Having corrected the nasal and 
the epipharyngeal disorders, the tubal inflammation often subsides 
without further treatment. Such a favorable result does not always 



686 THE EAR 

follow, however, especially if the mucosa has become hypertrophic or 
hyperplastic in character. In many cases there is a mixture of tumes- 
cence and hypertrophy, when local medical applications are only capable 
of removing the congestion and limiting the further development of 
the hypertrophic process. 

Perhaps the most useful method of applying remedies to the vault of 
the pharynx and the Eustachian orifices is by gargling after the von 
Troltsch method. The patient should lie on his back while gargling, to 
allow the fluid to enter the epipharynx. This is not difficult, as the head 
can be turned to one side in taking the fluid into and in ejecting it from 
the mouth. By following this method, the whole of the epipharynx, 
including the Eustachian orifices and the nasal chambers, may be 
reached by astringent and antiseptic remedies, with very favorable 
results. The deafness and tinnitus are often thereby relieved. 

Fig. 399 




G#a 6=#=© 



Buttles-Pynchon inhaler. 

The injection of from 1 to 4 minims of weak astringent solutions into 
each of the Eustachian tubes through a catheter is recommended. Care 
should be taken to avoid injecting it into the middle ear, as reactionary 
inflammation might follow. The syringe should be so gauged as to fill 
the catheter and leave a surplus of from five to ten minims. The extra 
solution is to allow for the inevitable escape of fluid into the epipharynx. 
The nose and the epipharynx should be sprayed with a 2 per cent, solu- 
tion of cocaine to reduce the sensibility of the parts before introducing 
the catheter. The solutions most often used are: (a) The iodide of potas- 
sium, 10 gr. to the ounce; (b) the bicarbonate of soda, 3 to 5 gr. to the 
ounce; (c) the sulphate of zinc, 1 gr. to the ounce; and (d) the nitrate 
of silver, 2 to 5 gr. to the ounce. 

Various vapors of iodine, ammonia, menthol, camphor, eucalyptol, 
etc., have been recommended. Iodine and ammonia are readily vola- 
tile, and the fumes therefrom may be sufficiently generated in a Buttles- 
Pynchon inhaler, shown in Fig. 399. A piece of sponge or cotton should 
be moistened with the desired solution and placed in the chamber of the 
inhaler. The inhaler should be connected with the catheter and air 
forced through it into the Eustachian tube. Another way of using the 
vapors of the foregoing drugs, either singly or in combination, is with 
a nebulizer. Either the nebulizer may be attached to the Eustachian 



TUBAL CATARRH 687 

catheter, or the vapors may be driven into the middle ear by the modified 
Politzer method, in which the nebulizing device takes the place of the 
rubber bag used by Politzer. In other respects, proceed according to the 
directions given under the Politzer method. The author has often put 
a few drops of the desired volatile solution into the Politzer bag and 
then practised inflation in the usual manner. 

The value of the foregoing topical remedies does not consist alone in 
the medicinal properties of the drugs, but includes also the mechanical 
effects of inflation. The current of compressed air directed into the 
orifice of the Eustachian tube removes the secretions and temporarily 
unloads the congested vessels and establishes normal glandular activity. 

If adhesive bands are present in Rosenmuller's fossa, the index finger 
of the right hand should be introduced through the mouth and the right 
fossa thoroughly curetted with the nail. The left index finger should be 
used to curette the left fossa. 

The principles to be observed in the treatment of tubal catarrh may be 
summarized as follows: 

(a) The correction of obstructive nasal lesions, and of inflammatory 
diseases of the nose and accessory sinuses. 

(b) The removal of neoplasms, adhesive bands, and other inflam- 
matory conditions in the epipharynx. 

(c) The topical application of antiseptic, astringent, and stimulating 
remedies to the mucosa of the Eustachian tubes. 

(d) The mechanical effects of inflation. 

(e) The administration of remedies to give tone and vigor to the 
general system. 

It should be said, in reference to the latter principle, that in many 
cases of deafness from tubal catarrh, the administration of tonics and 
other constructive remedies is often followed by an improvement in 
hearing. This is especially true in those cases in which there is no pro- 
nounced nasal or epipharyngeal disease. It is usually best to begin the 
treatment with a 2 to 3 gr. dose of calomel at bedtime, followed by a 
saline cathartic the following morning. After this, laxative doses of 
cascara may be given twice daily. The patient's alimentary tract is 
thus kept in a condition to care for and distribute the constructive 
remedies. These remarks are equally applicable to all catarrhal affec- 
tions of the upper respiratory tract. 

The Relation of the Eustachian Tube to Mastoiditis. — The 
Eustachian tube is adequate to drain all secretions from the middle 
ear, but it is often inadequate to drain the combined secretions of the 
middle ear, mastoid antrum, and cells, resulting in retention, pressure 
necrosis, and all the phenomena peculiar to mastoiditis. If the secre- 
tions from the antrum and mastoid cells are diverted from the middle 
ear, the Eustachian tube effectually drains it, and the diseased process 
rapidly improves. (See Author's Modified Radical Operation.) 



688 THE EAR 



OBSTRUCTION OF THE EUSTACHIAN TUBE 

Partial Obstruction.— Etiology.— Obstruction of the Eustachian tube 
may be due to a variety of conditions, namely: (a) Hypertrophy of 
the mucous membrane, especially in the pharyngeal or cartilaginous 
portion, the hypertrophy being an extension of the same process from 
the nose and the epipharynx. (b) Repeated inflammations, giving 
rise to a hyperplastic thickening and consequent obstruction, (c) 
Adhesive bands or constrictions forming in either the tympanic or the 
pharyngeal end of the tube, especially if the same pathological pro- 
cess is going on in the tympanic cavity, (d) Syphilis, tuberculosis, 
and diphtheria at the pharyngeal orifice, causing cicatricial contractions 
which more or less obstruct the opening, (e) Adenoids, while they do 
not grow from the Eustachian orifice, may be so large as to overlap 
and thus close it. (/) Paralysis of the palatal muscles from diphtheria 
and mixed infection, or from degenerative changes of the muscular 
fibers from repeated inflammations coincident with tonsillar inflamma- 
tion, giving rise to collapse of the muscular and other soft tissue at the 
pharyngeal orifice and thus causing its occlusion, (g) Adhesions of 
the posterior pillars to the tonsils interfere w T ith the muscular move- 
ments and contribute to the collapse of the Eustachian orifices, (h) 
Degeneration of the palatal muscles as a result of severe or repeated 
inflammation of the tonsils and contiguous structures, (i) Certain 
anatomical features, as exostoses and hyperostoses of the walls of the 
tubes, give rise to obstruction; there may be a sudden bend in the direc- 
tion of the tube, or the carotid canal may encroach upon it and thus 
obstruct it. (j) Adhesive bands in Rosenmiiller's fossa as described 
by Brunk. 

Diagnosis. — The diagnosis may be made by observing the charac- 
teristic retraction of the drumhead, foreshortening of the handle of 
the malleus, and the prominence of the short process and the posterior 
fold of the tympanic membrane. Postrhinoscopic examination may 
show either cicatricial contraction, overlapping adenoids, or collapse 
of the Eustachian orifice. The pillars (glossopalatine and pharyngo- 
palatine arches) of the fauces may be adherent to the tonsils, and cause 
more or less atony of the palatal muscles. The diagnostic tube used 
during inflation gives the strident or rough murmur characteristic of 
tubal obstruction. If the Eustachian tube is normally patent, the tubal 
sound is soft and blowing in character. 

Complete Obstruction.— This condition may be due to one or more 
of the causes given under Partial Obstruction, although it is usually 
due to syphilitic, tuberculous, or diphtheritic cicatricial contraction at 
the mouth of the tube. The symptoms are the same as in partial ob- 
struction, excepting that tympanic inflation gives no rale or murmur 
through the diagnostic tube. 

Undue Patency of the Eustachian Tubes.— This condition is nearly 
always associated with atrophic changes in the entire mucosa of the 



OBSTRUCTION OF THE EUSTACHIAN TUBE 689 

upper respiratory tract, especially of the nose, epipharynx, and oro- 
pharynx. The process may not involve the entire Eustachian tube, 
but may be limited to the pharyngeal orifice. Urbantschitsch reports 
a case of this kind in which the end of the little finger could be inserted 
into the orifice. 

The characteristic symptoms are the inward and outward movements 
of the drumhead synchronous with the respiratory movements, and the 
soft, blowing murmur heard through the diagnostic tube, even without 
inflation. There may be autophony or the ringing of the patient's 
voice in his own ears. The voices of others sometimes give rise to the 
same disagreeable sensation. The symptom is somewhat different from 
hyperesthesia acoustica, in which there is a painful distinctness of hear- 
ing; whereas in autophony the patient's own voice seems to ring or roar 
in his head. 

Treatment of Obstruction and Undue Patency.— The treatment 
of partial obstruction varies with the lesion causing it. If there is 
catarrhal congestion of the mucous membrane at the pharyngeal 
orifice, relief may be afforded by the judicious use of antiseptic and astrin- 
gent sprays in the nose and epipharynx. If, however, the hyperemia 
is due to anterior nasal obstruction, this should be corrected. The 
removal of adenoids is indicated to relieve the epipharyngitis and the 
resulting tubal catarrh, as well as to overcome the mechanical obstruc- 
tion they may form at the mouth of the tube. 

It is difficult to overcome cicatricial contractions, especially if it is due 
to syphilis. If due to diphtheria and tuberculosis, electrolysis may be 
of value. An olive-tipped electrode, with the curvature of a Eustachian 
catheter, should be introduced through a catheter. The tip should 
enter the Eustachian orifice to the isthmus of the tube. The shaft of 
the electrode should be covered with some insulating substance and 
the strength of the current should vary from 5 to 30 ma., according 
to the density and resistance of the tissue. Seances should last for 
from five to twenty minutes. The negative pole of the battery should 
be connected with the Eustachian electrode, as the tissue to be reduced 
is dense and fibrous. If it is a simple hypertrophy, the positive pole 
should be used. If the lumen of the tube is constricted higher up by 
adhesive bands, a small, gold-tipped electrode should be introduced 
through the Eustachian catheter until it comes in contact with the con- 
striction, as recommended by A. B. Duel. It is claimed for electrolysis 
in these cases that the obstruction disappears and the hearing and 
tinnitus are improved. Others have found it of no practical value. The 
status of electrolysis at best is open to criticism. The benefits derived 
from it within the Eustachian tube may well be attributed to the dilata- 
tion and inflation which are incidental to the procedure. Theoretically 
electrolysis is an ideal treatment for fibrous constriction, while practically 
it has been disappointing in the hands of most otologists. In obstinate 
cases it should, however, be given a trial, and will in some cases be 
attended with astonishingly good results. 

The use of bougies in reducing tubal stenosis has long been recognized 

44 



690 



THE EAR 



as of considerable value in those cases in which the stricture is not com- 
posed of connective tissue. If it is due to turgescence or simple hyper- 
trophy, the results are often good. The bougies may be made of silk- 
worm gut, whalebone, or celluloid. Those made of silkworm gut may 
be impregnated with astringent remedies, as silver nitrate, sulphate of 
zinc, etc., which often adds to the therapeutic effect. The whalebone 
bougie is easier to introduce on account of its polished surface. Cellu- 
loid bougies are also smooth and easy to introduce, but are more liable 
to break. 

Suarez di Mendoza has devised a metal catheter which may be removed, 
leaving the bougie in the Eustachian tube. The catheter is divided longi- 
tudinally into two parts, and it can be separated and removed, leaving 
the bougie in position. It is then cut off even with the nose and left 
in position for twenty-four hours. By this method, speedy dilatation 
is obtained. 

Fig. 400 




Weaver's intratympanic masseur. 



Caution. — The introduction of bougies into the Eustachian tube may 
injure the mucosa, hence emphysema of the submucous tissue may occur 
if inflation is practised immediately afterward. It should rather be done 
when the patient returns two days later for another treatment. The 
introduction of bougies may be practised two or three times a week. 
In favorable cases, the rough strident murmur heard through the diag- 
nostic tube during inflation will have been replaced, after a few treat- 
ments, by a soft, full, blowing murmur. 

In some cases great difficulty is experienced in passing the bougie 
beyond the pharyngeal orifice, as it bends and returns with a sharp 
tingling or smarting sensation in the lateral walls of the pharynx. The 
Eustachian catheter should be given a larger and sharper curve, so 
as to direct the tip of the bougie more in the direction of the lumen of 
the tube. 

The bougie should be pressed firmly against the constriction until 
it passes it, or until the hope of doing so is abandoned. When it is 
found impossible to pass the bougie, electrolysis should be tried. 
Larger bougies may be successively introduced until inflation gives 



OBSTRUCTION OF THE EUSTACHIAN TUBE 691 

a free, full, blowing murmur. After this they should be passed at 
longer intervals for several weeks or months. 

Massage of the Eustachian tube may be accomplished by the Weaver 
masseur (Fig. 400). The masseur is attached to the catheter and the 
current of air from the compressed-air tank turned on, the turbine wheel 
interrupting the current of air. The mucous membrane of the tube 
and middle ear is thus rapidly and intermittently compressed. The 
bloodvessels and lymphatics are unloaded, and the glandular elements 
are stimulated to greater activity. The tympanic cavity is inflated and 
the air tension restored. In turgescence and hyperemia of the tubal 
membrane, this method of treatment is highly commended. 

It should be said in conclusion that no one method of treatment is 
applicable to all cases. Each should be carefully studied and all the 
facts considered before determining the line of treatment. The nasal 
and epipharyngeal condition, as well as the general health, should be 
regarded as essential factors in determining the course of treatment in 
each individual case. 



CHAPTER XL 

THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 

The data of an anatomical, physiological, and clinical character, 
upon which the principles of tympanic inflation should rest, are as 
follows : 

(a) The Eustachian tube extends from the lateral wall of the epi- 
pharynx to the cavity of the middle ear in an upward, outward, and back- 
ward direction. If the head is rotated to the right and then inclined 
forward, the right Eustachian tube will stand perpendicular to the plane 
of the earth, thus favoring the drainage of the right middle ear. 

(b) The pharyngeal orifice of the Eustachian tube is trumpet-shaped; 
hence, when a current of air is forcibly thrown into it, the contained 
secretions are " dished" out and carried into the epipharynx, while the 
residual air passes on through the tube into the middle ear. 

(c) The walls of the Eustachian tube are covered with ciliated epi- 
thelium, the cilia creating a current toward the pharyngeal orifice. If 
the secretions are thick and become dried in the orifice, the sudden 
impact of air during inflation dislodges the mass and clears the way 
for the successful inflation of the middle ear. 

(d) The walls of the tubes are approximated when in the normal state 
of rest, and are only opened during inflation of physiological or artificial 
origin. 

(e) The drumhead, being the only yielding wall of the tympanic 
cavity, is pushed outward toward the external meatus during inflation. 

(/) The handle of the malleus is also carried outward, as it is in 
intimate relationship with the drumhead. 

(g) The incus and the stapes follow the outward movement of the 
malleus only to a limited extent, as the articulations are such as to per- 
mit the malleus to swing in this direction without marked movement of 
the other ossicles. The inward movement of the handle of the malleus 
is, however, accompanied by a corresponding, though more limited, 
movement of the incus and the stapes in the same direction. 

It is obvious, therefore, that in adhesive processes affecting the mo- 
tion of the malleus, inflation exerts more or less influence in breaking 
them down; whereas if the adhesions affect the incus and the stapes, 
but slight influence is exerted. 

(h) The mucosa of the tympanic cavity is supplied by numerous 
bloodvessels, capillaries, and lymph channels, which upon inflation (in 
catarrhal inflammation) become less engorged and return to their nor- 
mal state of fulness. In other words, inflation is followed by an active 
hyperemia and an approach toward normal physiological activity of 
(692) 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 693 

the tissues composing the mucous membrane. The secretions become 
thinner in character and approach the normal. They are, therefore, 
more easily carried toward the Eustachian tube by the wave-like motions 
of the ciliated epithelium. 

(7) The oxygen is gradually absorbed from the air within the tym- 
panic cavity, hence, after several hours, rarefaction takes place, thereby 
again causing the drumhead to retract. This does not occur in normal 
conditions, as air is admitted to the middle ear during each act of 
deglutition and yawning. 

(y) The palatal muscles have more or less control over the patency of 
the tubes, hence it is important that they be free to act to their full 
capacity. Repeated inflammations of the tonsils and fauces give rise 
to adhesions to the pillars of the fauces (glosso- and pharyngopalatine 
arches) and to degenerative changes in the muscular tissue. The action 
of the palatal muscles is thereby interfered with and the regulation of 
the patency of the tubes is impaired. The ventilation of the tympanic 
cavity cannot be fully accomplished, hence more or less deafness and 
tinnitus follow. 

(k) Passive congestion of the mucosa also results from the rarefaction 
of the air in the middle ear, and leads to abnormal activity of the mucous 
glands, as well as to a change in the character of the secretion. A true 
catarrhal state is thus induced. Repeated inflations, together with 
other appropriate treatment of the nose and throat, will, in many cases, 
be followed by a lessened congestion, a restoration of the glandular 
activity, and a return to the physiological ventilation of the tympanum. 

(J) Thick, tenacious secretion is not easily forced from the middle ear 
through the Eustachian tube by inflation. The circulation and the 
glandular elements of the mucous membrane become impaired. Never- 
theless, the thick tenacious secretion is gradually absorbed or discharged. 

(m) The transmission of sound waves through the ossicular chain to 
the labyrinth is only perfectly performed when the tension existing 
between the drumhead, the ossicles, and the intralabyrinthine fluid is 
normal. If the tension is disturbed, more or less impairment of the 
hearing results. Tympanic inflation restores the normal tension, unless 
adhesive bands prevent the drumhead springing into position. 

(n) When the drumhead is perforated, the secretion flows from the 
middle ear into the external auditory meatus. 

The foregoing data show that the objects of intratympanic inflation 
are as follows: 

1. To restore the normal tension between the drumhead, the ossicles, 
and the labyrinth. 

2. To restore the normal circulation in the bloodvessels and the lymph 
spaces. 

3. To render the secretions more nearly normal. 

4. To remove the morbid secretions from the Eustachian tube and the 
tympanic cavity. 

5. To break down newly formed adhesions. 

By establishing the foregoing conditions, tinnitus is relieved, hearing 



694 THE EAR 

improved, catarrhal inflammation checked, and the suppurative pro- 
cesses ameliorated. 

Methods of Inflation. — Valsalva's Method of Inflation. — While this 
method is not of such general utility as either Politzerization or cathe- 
terization, nevertheless it has a place in otological practice which is not 
filled by either of the others. Although its therapeutic effects are rather 
limited, it is of diagnostic value. 

The method consists in forcing the air into the middle ear by a forcible 
expiratory effort while the mouth and the nose are closed. The success 
of the effort is in proportion to the dynamic power of the muscles of 
the individual and the character and degree of the obstruction in the 
Eustachian tube. The muscular power in children and women is less 
than in adult males, hence it is proportionately less successful in the 
former. 

The hindrances to the successful performance of inflation are: (a) 
Thick, tenacious secretions in the mouth and the lumen of the tube, as 
well as in (b) the tympanic cavity, (c) When the tympanic cavity is in 
a state of partial vacuum from the absorption of the oxygen from the 
contained air, which causes the tympanic end of the tube to collapse 
by the suction thus created, (d) Fibrous adhesive bands resulting from 
chronic inflammation of the tubal membrane stretching across the lumen 
of the tube and obstructing it. (e) When the mucous membrane in a 
state of catarrhal inflammation is congested or even hypertrophied, thus 
interfering with tympanic inflation. (/) When the mucous membrane 
of the Eustachian tube is supplied with lymphoid tissue, which under favor- 
able conditions undergoes an hypertrophy akin to the same process in 
adenoids and tonsils, thereby diminishing the lumen of the tube, (g) 
Thick, tenacious secretions in the middle-ear cavity offering resistance 
to tympanic inflation, (h) The fact that there is no exit other than the 
Eustachian canal for the air entering the middle ear, a factor of some 
importance. It does not seem to the author, however, that it plays the 
major role assigned to it by some authors, notably Politzer, who thinks 
the drumhead offers considerable resistance. In such cases it is only 
necessary to open the Eustachian tube, when the air will rush in from 
the epipharynx to equalize the pressure on the two sides of the drum- 
head. This is the result of physical laws, and requires no force or 
artificial intervention other than a patent Eustachian tube. After this 
is accomplished, the air in the middle-ear cavity may be compressed 
even beyond the line of equilibrium, in order to stretch or break down 
adhesive bands, or to expel the secretions. 

The diagnostic value of this method is inferior to the others, inasmuch 
as it is less sure of being successful. In normal cases, when the desired 
result is obtained, a soft blowing sound is heard, which Politzer ascribes 
to the outward bulging movement of the drumhead. The author is 
inclined to take the view that it is due to the friction of the current 
of air in its passage through the collapsed Eustachian tube. If the 
tube is filled with secretions, as in moist tubal catarrh, the sound is 
changed to a moist bubbling murmur. 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 695 

The prognostic value of the method is considerable, in view of the fact 
that in those cases of catarrhal otitis media in which it can be successfully 
performed the prospects of cure or relief are good. 

Fig. 401 




Bulbous-tipped silver Eustachian catheter. 

Caution. — A word of caution should be given in regard to the evils 
attending Valsalva's method of inflation as a therapeutic measure. If 
the tinnitus and the "stuffed-up" feeling in the ears are relieved by this 
method, the patient is tempted to resort to its use so frequently and for 
so long a period of time that there is great danger of overstretching the 
membrana tympani, thereby rendering it atrophic. The author never 
recommends the method for therapeutic purposes, but, on the contrary, 
often discourages its use by those who have already adopted it. 

Fig. 402 




Showing a method of catheterization: a, the ring indicating the direction of the tip of the 
catheter; b, the posterior wall of the pharynx; c, c, the ridge forming the posterior lip of the mouth 
of the Eustachian tube; f, f, Rosenmiiller's fossa; b, d, e, the route traversed by the tip of the 
catheter to enter the mouth of the Eustachian tube. 



Catheterization. — Catheterization was first brought to the attention 
of the Paris Academy in 1724 by a postmaster named Guyot, but its 
therapeutic value was not clearly stated until a century later by Saissy, 
in his treatise on the Diseases of the Internal Ear, 1819. 

The Binnafont or Kramer method consists in introducing the catheter 
(Fig. 401) through the inferior meatus of the nose into the epipharvnx, 
where it is turned outward and upward into the mouth of the Eustachian 



696 THE EAR 

tube. The curved tip of the catheter should be kept on the floor of 
the nose at the junction of the floor and the septum. When the tip 
touches the posterior wall of the pharynx, it should be rotated outward 
into Rosenmuller's fossa, then rather quickly drawn forward over the 
bulging posterior lip (plica salpingopharyngeus) of the Eustachian 
orifice into the pharyngeal mouth of the tube. The eyelet of the catheter 
indicates the direction of the curved tip, which, when in the mouth 
of the tube, is generally turned in an upward and outward direction, 
toward the outer canthus of the eye. In some cases, however, the tip 
enters the orifice when directed horizontally outward (Fig. 402). 

It may be necessary to change the angle of the curvature of the tip to 
suit individual cases. Saissy recommended an angle of 130 degrees, 
while Politzer advises 145 degrees. 

The best instruments are made of pure silver, as they can be easily 
changed in shape and may be sterilized in boiling water, eliminating the 
liability to infection. Before the days of sterile surgery, hard rubber 
catheters were largely used, and they are still recommended by some 
authors. Saissy, however, nearly one hundred years ago, recommended 
silver, which is today preeminently the best material for the purpose. 

The Lowenberg Method. — The Lowenberg method consists in turning 
the tip of the catheter, after it has entered the epipharynx, toward the 
median line until the metal ring on the outer extremity assumes the 
horizontal position, and then drawing it forward until it touches the pos- 
terior extremity of the septum. In making the forward movement the 
outer extremity should be slightly removed from the septum, so as to 
bring the curved tip beyond the median line, thereby making sure that it 
catches on the septum. The outer end of the catheter should then be 
moved toward the nasal septum, and held near the tip with the fingers 
of the left hand. The tip should then be rotated downward and outward 
more than 180 degrees, or through more than half a circle, into the 
pharyngeal orifice of the Eustachian tube. If there is no malformation 
and the velum palati is not so tense as to displace the tip backward, 
it will enter the orifice, where it should be held during inflation. 

The fixation of the catheter, after it has been properly introduced into 
the pharyngeal orifice of the Eustachian tube, is most easily accom- 
plished by grasping the free end between the thumb and the forefinger, 
while the other fingers rest across the bridge of the nose. 

The auscultation or diagnostic tube (Fig. 403) should be used to deter- 
mine whether the catheter is in place. The statements of the patient on 
this point are not trustworthy, as the sensation produced by inflation 
often gives rise to a feeling of fulness in the ears when the auscultation 
tube does not confirm the patient's statement. The physician should 
make a common practice of using the auscultation tube when inflating 
the ears, not alone to judge whether the procedure is successful, but to 
enable him to determine the condition of the Eustachian tube and the 
middle ear. If there is a soft, blowing murmur, the tube is normally open, 
although it may be normally inflated and the murmur not heard. This 
is exceptional, however, and the fact of inflation can be demonstrated 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 697 

by using the manometer tightly fitted into the external auditory meatus. 
The U-shaped tube of the manometer should contain a few drops of 
colored fluid, which will rise in the outer arm of the manometer tube 
during inflation. If the Eustachian tube is obstructed by catarrhal 
swelling or hypertrophy of the mucous membrane, the character of the 
sound during inflation becomes sibilant and rough. The presence of 
mucus in the tube is indicated by moist bubbling rales. It occasionally 
happens that at the beginning of inflation there are signs of obstruction, 
which after a few moments suddenly disappear. In these cases it is 
probable that a thick plug of mucus obstructed the tube and was dis- 
lodged by the operation. In atrophic otitis media the Eustachian tube 
is correspondingly open, and inflation gives a very soft, blowing murmur. 

Fig. 403 




Inflation of the middle ear through a catheter attached to a compressed air apparatus, the 
American method. The catheter is held in position with the left hand, though not thus shown in 
the illustration. 



Other Methods of Catheterization. — There are several other methods of 
catheterizing the Eustachian tubes, not commonly used, that in excep- 
tional cases may be resorted to. 

(a) Catheterization from the opposite nasal cavity may be done with 
the ordinary catheter in those cases in which there is a narrow pharyngeal 
vault, by introducing the catheter along the floor of the nose in the usual 
way until it reaches the posterior wall of the pharynx, then rotating the 
curved tip toward the opposite Eustachian orifice until the ring on the 
outer end of the catheter stands horizontally toward the median line. 
The outer end of the catheter should then be removed from the septum, 
thus bringing the tip in approximation with the pharyngeal opening of 
the tube. Gentle pressure in a backward direction will bring it well 
into the opening. Inflation should then be practised in the usual 
manner. 

This method may be used when there is an obstructive lesion in the 
nose upon the side to be catheterized and in those cases in which there is 
congenital occlusion of the posterior nares on that side. 



698 THE EAR 

(b) Catheterization through the mouth may be done by using an 
instrument with a longer curve than is ordinarily used through the nose. 
The postrhinoscopic mirror will be found very useful in placing the tip 
in the mouth of the tube. When there is cleavage of the palate the 
ordinary catheter may be used, as the soft palate is out of the way, thereby 
enabling the operator to reach the mouth of the tube with the shorter 
curved tip. In many of these cases the operation may be accomplished 
without the use of the postrhinoscopic mirror, as the pharyngeal openings 
may be seen with the unaided eye. 

The Diagnostic and Therapeutic Value of Catheterization. — There are 
various methods of forcing air through the catheter into the middle ear, 
all of which are of value, the choice of method depending largely upon 
the mechanism afforded by the local instrument dealers rather than upon 
the peculiar merits of any individual method. 

(a) The Politzer bag, shown in Fig. 405, is connected directly with 
the Eustachian catheter, and is, perhaps, the most familiar apparatus 
for this purpose, owing to the reputation of its distinguished inventor. 
It is admirably adapted to the use of general .practitioners on account 
of its simplicity and the slight expense. 

(6) The equipment of a modern American otologist, however, usually 
affords appliances which are even more convenient, and perhaps more 
scientific in their application in office practice than the Politzer bag. 
Many offices in the large cities now have compressed air piped through 
the building, and with a gauge the desired pressure can be obtained 
for each individual case. An equipment of this character is admirably 
adapted to the purposes of the otologist, and renders the work of inflation 
more exact and scientific in its application. The shut-off should be 
applied to the expanded end of the catheter after it is properly adjusted, 
and inflation accomplished by liberating the air by means of the lever, as 
is done in spraying the nose and throat (Fig. 403). The exact amount of 
air pressure can be accurately estimated by the pressure gauge. The 
author uses the regulator attached to the compressed-air tank devised 
by Edwin Pynchon. It is so arranged that the amount of air pressure 
can be quickly adjusted to the needs of the case. A pressure of from seven 
to twenty-five pounds is all that is ordinarily required for the inflation of 
the middle ear. In some cases a pressure as low as five pounds is quite 
adequate for the purpose. 

(c) The nebulizing inflator is an instrument whereby inflation can be 
performed through the catheter in a very simple and easy manner. The 
tip of the nebulizer is made to fit into the expanded end of the catheter, 
and the medicated nebula is driven through the catheter into the middle 
ear. The impact of the medicated air thus released passes through 
the tube and the catheter to the middle ear. This appliance affords 
a convenient and simple means of applying medicated vapors. 

The diagnostic tube should be used in connection with these methods, 
and the character of the sounds transmitted through it noted for diagnos- 
tic and prognostic purposes. 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 699 

Politzer's Method. — In 1863 Politzer 1 introduced a method of inflating 
the middle-ear cavities which still proves of the greatest utility in aural 
practice. It is performed with a pyriform rubber bag (Fig. 404), of 
about ten ounces' capacity, to which is attached a nozzle suitable for 
introduction into the anterior nares. The patient is seated in front of 
the operator, the nozzle inserted well into one nostril, while the opposite 
nostril is firmly closed. The index and middle fingers of the operator's 
left hand should engage the tip of the nose, while the thumb completes 
the closure of the nostrils. The patient is then instructed to swallow, 
and as the laryngeal box is observed to rise, the bag is forcibly com- 
pressed with the operator's right hand. The nozzle and the operator's 
ringers completely close the anterior nares, while the act of swallowing 
brings the muscles of the soft palate and of the posterior wall of the 



Fig. 404 




Politzer's bag and tips. 

pharynx into apposition, thus completely walling off the respiratory path 
in that direction. The compressed air thus confined finds the point of 
least resistance via the Eustachian tubes, and is conveyed to the middle 
ear and inflation accomplished. The method is simple, the instru- 
ments of simple construction and slight expense, and the procedure is 
easily performed. The act of swallowing, if performed more than once 
or twice, becomes quite difficult for the patient unless aided by the 
use of a sip of water. 

Miot introduced a simple expedient which in some respects is more 
convenient than water. Sugar lozenges are kept on the treatment table, 
and one given to the patient before performing inflation. As the lozenge 
is dissolved in the mouth of the patient the act of swallowing is easily 

1 Wiener med. Wochenschrift, No. 6. 



700 THE EAR- 

and naturally performed as often as necessary without the inconvenience 
attending the use of water. The tubes may also be rendered patulous 
by uttering the sounds, och, k, king, kick, and by forcibly blowing out 
the cheeks. 

The author, in using the Politzer bag, places a piece of soft-rubber 
tubing, one foot long, between the tip of the bag and the nozzle (Fig. 405). 
By this measure the liability of mechanical injury to the mucous mem- 
brane of the nose when forcibly compressing the bag is avoided, and 
the hand of the operator has great freedom of movement within a circle 
of twenty-four inches' diameter. 

Auscultation during the use of the Politzer method shows two sets of 
sounds: one due to the entrance of air into the middle-ear cavity, the 
other to the escape of air in the epipharynx. The former is a soft, blow- 
ing murmur when the drumhead is intact, while the latter is rough, 
loud, and gurgling in character. After a little experience the tympanic 
sounds may be readily distinguished from the rough pharyngeal noises, 
and the latter are soon disregarded altogether. If for any reason the 

Fig. 405 



Politzer's bag and tube for use with a Eustachian catheter or nasal tip. 

tympanic murmur is not heard, the use of the manometer tube should 
be resorted to in order to determine whether the air is forced into the 
middle ear. 

It sometimes happens that inflation cannot be performed by Politzer's 
method, in which event the use of the catheter is usually indicated. 

A Modified Politzer Method. — The American Method. — The author 
uses a modification of Politzer's method, in which the rubber bag is 
discarded and the compressed-air apparatus substituted. It is not 
only a more convenient, but also a more exact method of inflation. 
A suitable nose-piece adapted to receive the tip of the shut-off of the air 
tank tube, such as is used with spray bottles, comprises the outfit. The 
Buttles-Pynchon inhaler is one of the best for the purpose, as it is 
constructed to be used with the ordinary shut-off of a compressed-air 
apparatus. It is a Pyrichon modification of the Buttles inhaler, in 
which the acorn-shaped nose-piece unscrews at about its middle portion 
(Fig. 399), thus affording an easy means of introducing pieces of sponge, 
gauze, felt, or cotton-wool upon which volatile medicaments may be 
dropped and blown into the tympanic cavity. By means of the com- 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 701 

pressed-air tank with a pressure regulator, the exact amount of air 
pressure needed to inflate the ear may be established for each case 
at the time of the primary examination. This should be made a part 
of the record, and utilized in the future treatments. If it is found after 
a few treatments that inflation is accomplished with less air pressure 
than was at first required, a favorable prognosis may be given. The 
great advantage of this method over Politzer's is the fact that the amount 
of pressure used can be accurately estimated, regulated, and recorded. 
This method should be adopted in all modern offices, but for bedside 
practice and for home use the Politzer bag still holds a distinct and 
useful place in otological practice. 

Thomas Hubbard has also devised an ingenious compressed-air 
apparatus for the graduated and scientific regulation of the air pressure 
in tympanic inflation. His apparatus is also provided with an air filter. 

External Mechanical Massage. — In the hands of the author external 
mechanical vibration below the angle of the inferior maxilla has proved a 
valuable adjunct to the inflation of the middle ear. In some cases which 
resist successful inflation, mechanical massage applied in this region 
with the vibrator will bring about the desired result. The mechanical 
vibration thus imparted probably lessens the passive congestion of the 
mucosa of the pharynx, tonsils, and faucial pillars, and thus favorably 
influences the mouth and the lumen of the Eustachian tube. 

Comparative Value of the Methods. — It may be said that no one method 
should be used to the exclusion of all others. Each will, under certain 
circumstances, answer the purpose better than another. The condi- 
tions favorable to the employment of any method cannot always be 
foreseen, but can only be ascertained by trial. The author has often 
found it impossible to inflate by catheterization when he could do it 
readily by the Politzer method, or vice versa. He has also found the 
Politzer method inadequate in some instances in which the modification 
described by the author, using the compressed-air tank and a nose-piece, 
did the work satisfactorily. 

Valsalva's method is commended on account of its simplicity and the 
absence of instruments of any kind in its performance. On the other 
hand, it is to be strongly condemned on account of the ease with which 
it may be 'abused. It is done entirely by the patient, and the relief it 
affords may tempt him to resort to its use much oftener than is neces- 
sary or safe. There are few cases requiring inflation oftener than once 
on each alternate day for a period of six weeks. With Valsalva's method 
the patient often inflates his ears several times daily for many weeks 
or months, thus producing pressure atrophy of the drumhead. When 
this condition arises, the state of the patient's ears is worse than before 
treatments were given. 

Catheterization is regarded by many as the most effective method of 
inflation yet devised. In the author's experience, a louder tympanic 
murmur is heard by this than by any other method. He believes, there- 
fore, that where it can be used without great discomfort to the patient it 
should be given preference. However, there are certain nasal deformi- 



702 THE EAR 

ties which may prevent, or at least greatly hinder, its successful use. 
Some other method, preferably the tank and nose-piece, should then be 
used. Politzer himself claims more for his method than for any other, 
not excepting catheterization. 

The Politzer method is extensively recommended and used on account 
of its simplicity and the ease with which it is practised. In those cases 
in which the catheter cannot be used, as in marked nasal obstruction, 
hypersensitiveness of the mucosa, timid patients, and children, it should 
be elected as preferable to catheterization. 

Unless the diagnostic (auscultation) tube is used, the operator is 
never certain of the results obtained by any method whatsoever, the 
patient's statements often being untrustworthy. 

The modified Politzer method, in which the compressed-air tank takes 
the place of the rubber bulb, is ordinarily preferable to the Politzer 
method, as the pressure can be accurately regulated to suit each case. 
The tympanic murmur is louder and is heard much longer and more 
continuously on account of the constant air pressure than with the short 
puff obtainable with the Politzer bag. The author believes, however, 
that where catheterization can be done with little discomfort to the 
patient, it should be given preference. 

Recapitulation. — 1. Catheterization is the most effectual method of 
inflation in most subjects. 

2. The compressed-air tank and nose-piece are preferable if for any 
reason catheterization cannot be performed. 

3. The Politzer method should be used in bedside practice and as a 
"home treatment/' and in all other instances in which the compressed- 
air apparatus and nasal tip are not available. 

4. Valsalva's method should only be recommended when the others 
are not available, and then only with strict instructions as to its possible 
evil results if the directions as to the frequency and period of use are not 
strictly followed. 



CHAPTEK XLI 

INFLAMMATORY DISEASES OF THE TYMPANUM 
ACUTE CATARRHAL OTITIS MEDIA 

Acute catarrhal otitis media comprises about 13 per cent. (Hovell) of 
all ear diseases ; it is, therefore, a very important division of otology, and 
should be considered in some detail, especially in view of the fact that 
the general practitioner is so frequently called upon to treat it. 

General Etiology. — The causes of simple catarrhal otitis media are 
numerous, and may be considered under three different headings, 
namely: 

1. Exciting causes, or pathogenic microorganisms. 

2. External influences, or those conditions external to the body which 
act as predisposing causes. 

3. Internal influences, or those conditions within the body which pre- 
dispose to otitic inflammations. 

1. Exciting Causes. — The exact relation of microorganisms to the inflam- 
mation of the middle ear is not yet fully determined. That they are 
found in healthy ears is probable, as the investigations by Zaufal have 
shown them to be present in the ears and epipharynx of rabbits. We 
know that the various infectious fevers, as scarlet fever, measles, 
diphtheria, etc., are often accompanied by acute catarrhal otitis media, 
although complications from these sources are very prone to take on the 
suppurative type. There is no special bacteria which causes catarrhal 
inflammation of the middle ear, but there is usually a combination of 
two or more, such as the Diplococcus pneumoniae and the Streptococcus 
pyogenes. The Staphylococcus pyogenes albus and aureus, and the 
Bacillus pyocyaneus are next most frequently found in the middle ear. 
Friedlander's bacillus is less frequently found in combination with the 
Staphylococcus cereus albus, Bacillus pyocyaneus, and the Micrococcus 
tetragenus. These and other microorganisms may be present in the 
tympanic cavity without exciting inflammation. It is necessary that the 
conditions of the secretions and the tissues be favorable for their rapid 
propagation before they are able to excite an inflammatory process It 
has been found that the invasion of a new microorganism is sufficient, 
under certain circumstances, to excite inflammation. After the inflam- 
mation has subsided, the invasion of another type of microorganism may 
cause a recurrence of the inflammation. The question of microorgan- 
isms in their relation to inflammatory processes is still involved in so 
much speculation and doubt that it is impossible to give any definite 
statement as to the exact influence they have as etiological agents in 

(703) 



704 THE EAR. 

catarrhal inflammations. It seems that after the primary irritation of 
the tissues has subsided, the soil is prepared for other germs, so that 
upon their entrance there is a recrudescence of the inflammatory process. 

It is well known that pathogenic microorganisms are more virulent 
at times than at others, hence the presence of microorganisms per se is 
not sufficient to cause acute inflammation. They must be of the proper 
virulency, the soil must be prepared to favor their activity, and the 
cellular structures must be so modified in their functional activity as to 
be unable to resist their influence. Even the tubercle bacillus may be 
found in the secretions of the middle ear without giving rise to patho- 
logical changes. 

Channels of Invasion. — Microorganisms nearly always gain access to 
the tympanum through the Eustachian tube. There are several other 
routes, however, through which they may enter it. The bloodvessels 
may carry them to the mucous membrane of the tympanum, where they 
may be thrown out with the serum and mucus, and thus give rise to 
inflammation. They may also gain access through the drumhead, 
when it is perforated, either from congenital or pathological states. In 
rare instances they may gain entrance from the cranial cavity through 
the bony walls, or through the internal auditory canal and labyrinth. 

As has been stated, they most frequently gain entrance through the 
Eustachian tube. This may occur in spite of the fact that the tube is 
lined with ciliated columnar epithelium, whose cilise create a current 
toward the epipharynx. The Eustachian tube is patent as it momentar- 
ily opens to admit air into the tympanum, and the microbes may be swept 
inward with the current of air to the middle ear. This may also take 
place during paroxysms of sneezing or vomiting. Hence, there is no 
absolute physiological barrier offered by the ciliated epithelium of the 
tube to the entrance of microorganisms into the middle ear. 

The microorganisms excite catarrhal inflammation which may assume 
the suppurative type. They may also be present without exciting any 
pathological reaction. 

2. External Influences. — The external causes of otitis media cannot 
be considered without also taking into account the internal conditions 
which predispose to it. It is convenient, however, for purposes of study 
to consider the external causes separately, and in so doing we shall have 
to take into consideration the local conditions of the upper respiratory 
tract, as well as certain constitutional states which will be considered 
in detail under the second type of general causes. 

Exposure to the weather is a fruitful predisposing cause of otitis media, 
especially when the tone of the system is not up to the normal standard. 
If the patient has chronic rhinitis or obstructive disease of the nasal 
cavities, or has adenoids and epipharyngeal inflammation, exposure 
to the inclemencies of the weather is especially liable to result in acute 
catarrhal inflammation of the middle ear. Certain other factors enter 
into this proposition, as clothing, climate, zone, age, sex, and the occu- 
pation of the patient. 
. It seems appropriate, therefore, that these etiological factors should be 



ACUTE CATARRHAL OTITIS MEDIA 705 

considered under this heading, rather than under separate paragraphs. 
It is evident that the effect of exposure to the weather will depend very 
largely upon the amount and kind of clothing worn, and the climate and 
latitude in which the patient lives, as well as upon his occupation. Age 
and sex will, also, largely determine this effect. The character and 
amount of clothing worn does not, per se, determine the influence that 
exposure to the weather will have upon the patient, as the habits of the 
individual and the character of the house in which he lives modify his 
susceptibility to such exposure. If he lives in a house that is but partially 
heated, and has been accustomed to sleeping in a bedroom which was 
never heated, the exposure to the inclemencies of the weather will not 
affect him as much as it will one who lives in a well-built house which is 
uniformly heated. 

Many of our country homes are so loosely constructed that they are 
well ventilated through the crevices about the windows and doors. There 
is not, therefore, the extreme difference between the conditions indoors 
and outdoors found in the better portions of the large cities. 

Those living in country houses are subjected to a more even tem- 
perature and atmosphere, within and without the house, than those 
who live in closely built and better heated houses. They are, there- 
fore, not so susceptible to changes of the weather, and the amount of 
clothing they wear, when exposed, need not differ so much in quantity 
and character from that worn while indoors. 

I have known patients accustomed to country life, who were exposed 
to the inclemencies of the weather a hundred times more than they 
were in after years when living in the city, to be entirely free from catar- 
rhal conditions of the nose and ears while living in the country, and 
rapidly develop them after removing to the city. 

The catarrhal inflammation developed, in spite of the fact that they 
were taking extraordinary precautions, in the way of additional clothing, 
to protect themselves while outdoors. It seems, therefore, that the 
habits of life which tend to lower cell vitality have more to do with 
the predisposition of the upper respiratory tract to catarrhal inflam- 
mation than the amount or character of clothing worn. Our modern 
dwellings with their superb heating plants, storm windows, etc., are, 
perhaps, less of a boon to humanity than is generally supposed. The 
more primitive style of living seems to accustom the system to the vari- 
ations in the temperature and hygroscopic conditions of the atmosphere. 
It is not reasonable, however, to expect that we will return to that mode 
of living. We can only say in this connection that in the construction 
of our houses more attention should be given to the question of ventila- 
tion. It has been said that good ventilation and cheap heating do not 
go hand in hand. Within certain limits this is undoubtedly true. Never- 
theless, the architect can do much toward the proper ventilation of 
dwelling houses without materially increasing the expense of heating. 

The attention of the public should be frequently called to this fact 
until they are educated up to the point that they will demand that this 
problem receive appropriate attention at the hands of the architects. 
45 



706 THE EAR 

The climate and latitude in which one lives influence, in a marked 
degree, the character and amount of exposure to which he is subjected. 
In the temperate zone the climate is usually variable and subject to 
very rapid changes in temperature and hygroscopic conditions of the 
atmosphere, and is, therefore, one of the factors in the etiology of acute 
inflammations of the upper respiratory tract and middle ear. Those 
living in the more frigid and torrid zones are less exposed to sudden 
changes in the temperature and atmosphere, and are, consequently, less 
subject to catarrhal inflammations. Those living near large bodies of 
water, as the ocean, or the chain of Great Lakes between Canada and 
the United States, are especially affected by climatic conditions, as the 
atmosphere is moist and penetrating. The skin is thereby chilled and the 
vasomotor nervous centres are disturbed, and many of the functions of 
nutrition and metabolism are modified in such a way as to excite inflam- 
matory processes in the mucous membranes, especially those of the 
respiratory tract. 

Certain occupations give rise to greater exposure than others, conse- 
quently sex, which largely determines the nature of one's occupation, 
must have some influence in the etiology of this disease. A greater pro- 
portion of males are exposed to the inclemencies of the weather; hence, 
catarrhal inflammation of the mucosa is more common with them than 
females. 

Age also determines, to some extent, the amount of exposure. Young 
male adults in the vigor of life, full of ambition and enterprise, more 
often subject themselves to the inclemencies of the weather in the pur- 
suit of their vocations than those who are younger or older. Hence, 
we find catarrhal inflammation of the middle ear and upper respiratory 
tract more common in young adulthood than at any other period of 
life. 

A careful study of the above facts will demonstrate that exposure to 
the weather is a question of considerable complexity, as the effects of the 
exposure are largely determined by the mode of life, clothing, zone, age, 
sex, and occupation of the patient. It is not sufficient, therefore, for one 
to say to the patient, " You should not expose yourself to the inclemencies 
of the weather." All the facts pertaining to his mode of life should be 
taken into consideration, and advice given accordingly. It has become 
quite the fashion nowadays to tell patients that they should take a cold 
plunge bath each morning, and that they should walk at least five miles 
a day. This advice with certain limitations is sound, and is based upon 
the data given above. The attempt is made by this procedure to bring 
the patient for a brief time each day back to the primitive methods of 
living. It is well known that life in the open air, and a certain amount 
of exposure of the body to varying degrees of heat and cold, are favor- 
able to the well-being of the system. 

More attention should be given to this subject than is now done. 
The influence of open air upon the cellular vitality is greater, perhaps, 
than is generally appreciated. We know that many women work indoors 
all day, are constantly making physical exertion, and are anemic and 



ACUTE CATARRHAL OTITIS MEDIA 707 

poorly nourished in spite of the fact that they have plenty of wholesome 
food. The same amount of exercise taken in the open air would trans- 
form them into robust, red-blooded women. Fresh air is the most 
potent therapeutic agent for the upbuilding of the system. 

3. Internal Influences.— The internal conditions which predispose to 
catarrhal inflammation of the middle ear and upper respiratory tract 
have a more intimate clinical relationship to acute catarrhal otitis media 
than the external influences. It is well established that middle-ear dis- 
ease is almost invariably preceded by some form of nasal or epipharyn- 
geal disease. Whatever causes the preexisting infection and inflamma- 
tion of the nasal mucous membrane or the mucosa of the epipharynx 
will also directly or indirectly lead to a similar condition within the 
Eustachian tube and middle ear. This is easily accounted for when we 
remember that the mucous membrane of the Eustachian tube and 
middle ear is a continuation or reflection of that lining the nose and 
epipharynx. It is quite similar in physiology and structure, and inflam- 
mations therefore readily extend from one part of it to another. If there 
is a difference in the structure of the mucous membrane, as in the meso- 
pharynx, where the epithelium is squamous, the inflammatory process 
does not readily extend to that part. The mucosa of the nose, epi- 
pharynx, Eustachian tube, and middle ear are lined by columnar ciliated 
epithelium; hence, there is no bar to the extension of the inflammatory 
process from one to the other. 

In this connection it is of advantage to briefly refer to the diseases of 
the nose, epipharynx, and fauces which cause inflammatory diseases 
of the Eustachian tube and middle ear: 

(a) Nasal diseases which cause pathological processes within the 
middle ear are either inflammatory or obstructive in character. The 
inflammatory diseases are acute rhinitis, acute fibrinous rhinitis, diph- 
theritic rhinitis, syphilitic rhinitis, tuberculous rhinitis, and catarrhal and 
suppurative sinuitis. The inflammation may extend to the middle ear 
through the Eustachian tube by continuity of tissue, or the pathogenic 
bacteria may invade the ear through the Eustachian tube or through 
the blood and lymph channels. They also influence the inflammatory 
changes in the middle ear by causing the closure of the Eustachian tube, 
thereby interfering with the ventilation of the tympanum. The oxygen 
is gradually absorbed from the middle ear, thus gradually rarefying the 
air. The blood within the vessels of the mucos? of the middle ear rushes 
in to fill the partial vacuum thus created, and congestion and engorge- 
ment of the mucous membrane follow. This leads to changed nutrition 
of the parts and to a disturbed relationship of the cellular structures, 
which after a time predisposes to an inflammatory process. 

Nasal obstruction is also a fruitful source of ear disease. The pres- 
ence of spurs, ridges, thickening, and deflections of the septum, and 
enlargement of the middle turbinate (see Vicious Circle of the Nose) 
cause stenosis of one or both nares or obstructs the ostia of the sinuses. 
As the nasal cavities are the natural channels for the respiratory and 
expiratory currents of air, any interference with their patency results 



708 THE EAR 

in physiological disturbances of a very pronounced character. When 
the diaphragm contracts, the thoracic cavity is enlarged and the air 
from without rushes in to fill the increased space. If the nasal chambers 
through which the air enters the respiratory tract are obstructed, the 
contraction of the diaphragm acts as the valve in a syringe when it 
is forcibly pulled out; the air is thus rarefied posterior to the point of 
obstruction. The partial vacuum thus created is attended with the rush 
of blood to the vessels of the mucosa. This condition after a time leads 
to tissue changes and predisposes to inflammatory processes. The 
patency of the Eustachian tubes is thereby diminished, which still further 
affects the middle ear. Hence, nasal and sinus obstruction is a constant 
menace to the middle-ear cavity. 

All cases should be carefully examined for any diseased state of the 
nose, as the subsequent treatment of the case will depend very largely 
upon the successful treatment of the nasal conditions. 

Ethmoiditis and sphenoiditis are a fruitful source of middle-ear inflam- 
mation. The morbid secretions from these cells flow into the epipharynx 
and excite an inflammation which in time extends by continuity of 
tissue to the Eustachian tube and middle ear. 

(b) Epipharyngeal diseases predisposing to middle-ear catarrh may be 
studied under two headings; namely, postnasal adenoids, or neoplasms, 
epipharyngitis and adhesive bands in Rosenmuller's fossae. The pres- 
ence of postnasal adenoids in the vault of the pharynx gives rise to 
epipharyngitis, either of the catarrhal or suppurative type. For reasons 
already given, this inflammatory process may give rise to middle-ear 
inflammation. Postnasal adenoids may be so situated as to close the 
mouths of the Eustachian tubes, a common cause of middle-ear 
catarrh. 

(c) Enlarged or diseased faucial tonsils have for many years been 
recognized as one of the principal etiological factors in the production of 
middle-ear disease. This relationship is readily understood when we 
remember that the tonsils are situated between the anterior and posterior 
pillars of the fauces (glosso- and pharyngopalatine arches). The pos- 
terior pillar embraces the palatopharyngeus muscle, which has some 
influence in controlling the patency of the Eustachian tube. It is appar- 
ent that when the tonsils are diseased the pillars are congested or inflamed 
and in time their muscular fibers undergo more or less degeneration 
and atrophy. 

(d) Tubal disease, while intimately associated with middle-ear disease 
in nearly every case coming under observation, may be present without 
a similar process in the middle ear. In other words, there is a time 
when the inflammation extends from the epipharynx into the Eustachian 
tube, and does not yet involve the middle ear. Reference has already 
been made to the fact that congestion or obstruction of the Eustachian 
tube is a fruitful source of inflammatory diseases in the middle ear, 
and need not be dwelt upon at greater length in this place. 

(e) Constitutional disorders, as anemia, scrofula, syphilis; and tuber- 
culosis, lower the vitality and thus predispose the middle ear to inflam- 



ACUTE CATARRHAL OTITIS MEDIA 709 

rnatory attacks. This has already been referred to under the external 
causes of otitis media. 

After all that has been said as to the causes of otitis media, we may 
go back to the primary statement that those influences external to the 
body which, under varying circumstances, affect the vasomotor system, 
and' certain diseased states of the epipharynx, cause obstruction of 
the Eustachian tube and subsequent infection and inflammation of the 
middle ear. 

Pathology. — The cavum tympani contains serum admixed with mucus 
in varying proportions. Epithelial cells are also found in the secretion. 
They show evidence of having undergone degenerative changes peculiar 
to inflammatory processes. While the secretion cannot be said to be sup- 
purative in character, it may contain a number of pus corpuscles. The 
mucous membrane of the middle ear, unlike that of the nose, has very 
few glands; hence, the mucus is formed from the chalice of goblet cells 
of the mucosa. In the nose the mucus is chiefly formed by the cells 
lining the glands, only a few goblet cells participating in its production. 
There is, therefore, in the middle ear a very rapid degenerative process 
(mucoid degeneration) going on during the acute inflammatory process. 
The intercellular spaces are filled with fluid, while the bloodvessels are 
very much congested, thus rendering the membrane very much swollen 
and thickened. The surface of the mucous membrane is denuded of 
epithelium in patches. Hovel calls attention to the fact that leukocytes 
are found mingled with the secretion in the immediate region of these 
patches. 

Pronounced destructive processes are not commonly present in this 
type of middle ear disease. In rare instances the drumhead is perforated, 
while there is more or less maceration of the mucous membrane lining 
the tympanic cavity. After a few days the morbid changes described 
above rapidly disappear, the mucous membrane returning to its normal 
condition. There remains, however, a peculiar susceptibility to recur- 
rent inflammations. This may be due to the fact that microorganisms 
of the proper virulency gain entrance to the cavity and, finding the soil 
prepared by the primary inflammatory process, readily excite a recur- 
rence of the inflammation. 

General Symptoms and Diagnosis.— Acute otitis media is usually 
due to a bacterial infection via the Eustachian tubes, though it occa- 
sionally enters via the blood current. The exudate may be simple or 
purulent. In simple catarrhal inflammation the drumhead rarely rup- 
tures, no matter how intense the inflammation may be. If the exudate 
is purulent there is a tendency to rupture at the point of greatest bulging. 
Severe simple catarrhal cases begin with the same constitutional dis- 
turbances present in severe purulent cases, namely, chills, fever, vomiting, 
and prostration. It is often quite difficult to differentiate between acute 
non-suppurative and acute suppurative otitis media, until the drum 
membrane ruptures. Both types of inflammation are due to infection, 
one undergoing resolution before suppuration, and the other passing 
into the suppurative stage. 



710 THE EAR 

Intracranial complications never occur in acute non-suppurative 
otitis media, and somewhat rarely in the acute suppurative variety. Such 
complications occur more often in the chronic type, with acute exacer- 
bations. 

The exudate has a tendency to become organized into adhesive fibrous 
bands, hence it is very important that their absorption should be has- 
tened as much as possible. The air douche, by means of the Politzer 
bag and the catheter, should be used to clear the middle-ear cavity of the 
exudate, or at least to spread it over a larger surface, thereby reducing 
the amount of exudate at any one point. The inflations should be 
repeated from time to time until the ear is free from the exudate, as shown 
by the auscultation tube. According to Edwin Pynchon, the use of the 
continuous air douche through a Eustachian catheter will abort acute 
otitis media. A pressure of about five pounds is required for this purpose. 
The compressed-air tank should be adjusted to this pressure and the 
current of air passed through the catheter into the tube and middle-ear 
cavity. 

Infaflts often have acute otitis media of very short duration, probably 
of pneumococcal origin. Intestinal disturbances in infants are often 
accompanied by ear infection, and an examination of the ear should 
always be made. The exanthematous fevers of childhood are common 
causes of middle-ear infections, which in later years result in many 
deaths from meningitis, sinus thrombosis, brain abscess, etc. Great 
pains should be taken in these diseases to keep the nose and epipharynx 
clean during the fever. Scarlet fever and measles are especially destruc- 
tive in this way. Diphtheria more rarely invades the middle ear. 

Acute tuberculous otitis media is seldom accompanied by pain. This 
is in striking contrast to other types of acute infection. If an acute 
tuberculous otitis media begins with pain and other symptoms peculiar 
to the ordinary acute suppurative otitis media, the prognosis is much 
more favorable than in the non-painful variety. 

Acute otitis media occurring during diabetes is not of diabetic origin. 
The occurrence of the two diseases is accidental. The diabetic disease, 
however, gives rise to constitutional disturbances which favor the long 
continuance of the ear discharge. 

Neglected cases of chronic catarrhal otitis media result in shrinking 
and atrophy of the mucous membrane, or adhesions may form, thus 
causing permanent loss of hearing. The deposit of lime salts or adhesive 
processes may fix the ossicles or bind them to the contiguous walls of the 
cavum tympani. 

Symptoms. — The symptoms of this disease vary according to the 
period of time which has elapsed since the onset. At the beginning 
they are much more pronounced than they are after a few days, when 
the more acute inflammatory process has begun to subside. 

1. The onset of acute otitis media is usually signalized by a slight 
drill, which is quickly followed by a temperature ranging from 99° to 
102°. The fever is, however, of such slight character in most cases that 
the attention of the patient is not usually attracted to it. The symptom 



ACUTE CATARRHAL OTITIS MEDIA 711 

which quickly develops, and which should demand the attention of the 
attending physician, is the pain, which may be characterized as a dull, 
boring, aching sensation, or it may assume a more acute type, and 
become excruciating in its intensity. It is usually intermittent or throb- 
bing in character, synchronous with the pulse beat at the WTist. It 
is due to the great swelling of the drumhead and mucous membrane 
of the middle ear, whereby the sensitory nerve filaments are put "on 
the stretch" with each arterial pulsation. It may also be due to the 
bulging of the drumhead outward into the meatus. There is a great 
amount of intercellular fluid thrown out at this stage of the disease, 
which together with the congestion of the bloodvessels renders the 
mucous membrane and drumhead very much thicker than normal. 

In the first stage the drumhead is very red and thickened, and the 
handle of the malleus obscured from view. Its surface may present the 
appearance of a piece of raw beefsteak, except that it is more velvety 
in its texture. The drumhead may or may not bulge into the external 
meatus, depending upon the amount of secretion within the middle 
ear. 

If the middle ear is filled with exudate, the drumhead is of necessity 
pushed outward. If, however, it is only partially filled, it may remain in 
its normal position or even be retracted. 

Auricular tenderness is sometimes present, especially over the tragus. 
The mastoid process may or may not be tender upon percussion or 
pressure. Pressure over the mastoid antrum nearly always elicits 
tenderness, though it may be slight. 

Bone conduction is increased on the affected side. The lower tone 
limit is lost, while the upper tone limit is not affected in those cases in 
which the labyrinth is not involved. If the disease is unilateral, the 
Weber experiment lateralizes to the affected side. The Rinne test is 
usually negative in character. By the term negative, I do not mean that 
it shows nothing, but that bone conduction for the tuning fork over the 
mastoid process is longer than by air conduction when the fork is held 
near the external auditory meatus. If the labyrinth is involved, bone 
conduction is diminished, and the Weber test shows the sound lateralized 
to the unaffected ear, while the Rinne test gives a positive sign. Laby- 
rinthine involvement is, however, very rarely present in simple catarrhal 
otitis media. 

2. The second stage of this disease is characterized by the disappear- 
ance of the pain, fever, and redness of the drumhead. The congestive 
phenomena are lessened in intensity, hence the drumhead and mucous 
membrane are less thickened and swollen. The drumhead, instead of 
being beefy or purplish red in color, is yellowish or greenish in tint. 
The change in color may be explained by the fact that there is less 
blood in the drumhead, and the pale, slightly greenish secretion in the 
middle ear is seen through it. The greenish-yellow color often gives 
rise to the idea that there is pus in the middle ear. 

Another symptom of considerable significance is the presence of a 
dark wavy line (Fig. 406) extending in a nearly horizontal direction 



712 



THE EAR 



across the drumhead. This line, which is 1 to 2 mm. in thickness, is due 
to the peculiar refraction of light at the junction of the viscid secretion 
and the air in the tympanic cavity. If it is below the umbo, it is usually 
concave on its upper surface; whereas if it extends above the umbo, it is 
usually composed of two concave surfaces. The line will be higher or 
lower on the face of the drumhead according to the amount of secretion 
in the middle ear. If the middle ear is completely filled, the line will not 
be visible. 

The 'position of the head determines the direction of the line, as the 
fluid gradually seeks the level of the new position (Fig. 407). The viscid 
nature of the secretion and the narrowness of the tympanic cavity inter- 
feres with the rapid change in the position of the secretion. The line is 
often not visible, on account of the great thickness and congestion of 
the drumhead. 



Fig. 406 



Fig. 407 





Right membrana tympani, showing mucus 
secretion and air bubbles after tympanic in 
flation. 



Right membrana tympani with mucus secre- 
tions and air bubbles after tympanic inflation, 
the patient having just arisen from the prone 
position. 



Another symptom is the presence of oval or round rings (Figs. 406 and 
407), which are due to the air bubbles in the viscid mucus. They may 
extend above the dark line, described above, or they may be within 
the field of the mucus itself. They may be single or multiple. After 
tympanic inflation the line disappears, while the entire field of the 
drumhead is occupied by the air bubbles. After several hours they will, 
in part, disappear, and the line will return. 

Aural auscultation, if used during the process of tympanic inflation, 
shows the presence of moist rales, due to the air passing through the 
viscid mucus. They are very different in character from the soft, blow- 
ing murmur heard during inflation of the normal ear. 

The first inflation may not be successful, as the Eustachian tube is 
filled with viscid mucus; hence, it should be repeated several times. 
The diagnostic tube should always be used in performing tympanic 
inflation. 

The membrana tympani may or may not bulge into the auditory 
meatus, as this depends upon the amount of secretion within the middle 
ear. When it bulges into the meatus it is a positive indication that 



ACUTE CATARRHAL OTITIS MEDIA 713 

paracentesis, or incision of the eardrum, should be performed. To 
neglect this subjects the patient to unnecessary pain and to sponta- 
neous perforation of the membrane. Spontaneous perforation should 
not be allowed to occur, as the perforating process is due to necrosis. 
Not only is irreparable damage thus done to the drumhead, but other 
parts are subjected to pressure and to possible ulceration and necrosis. 

Incision of the membrana tympani should, therefore, be done early, to 
prevent great destruction of tissue and to promote the reaction of inflam- 
mation. The incision does not result in scar tissue, which usually follows 
spontaneous rupture of the drumhead. 

It should be made at the most bulging portion, and should be crucial or 
V-shaped in character and from |- to f inch in length. Simple para- 
centesis, while often recommended, is not sufficient for free drainage 
of the tympanic cavity. If the incision is made straight and the drum- 
head is tense, the aperture for the discharge of secretion is very small, 
while the crucial or curved incision forms a slight flap, which permits 
a larger opening for the discharge of the tympanic contents. 

Bone conduction is increased and the Weber and Rinne experiments 
give the results described under the onset of the disease., 

Prognosis. — This is favorable or unfavorable according to the period 
at which treatment is instituted. If the case is seen early and appropriate 
remedies are used, favorable results will follow in nearly all cases. If, 
however, the case is allowed to run on for some time before treatment 
is commenced, changes of considerable importance may have taken 
place, such as adhesion of the contiguous parts, and ulceration in the 
superficial portions of the mucous membrane, the prognosis is not so 
favorable. 

There are certain conditions which render the prognosis less favorable, 
as syphilis, tuberculosis, anemia, etc. It is obvious that if the diseases 
of the nose, epipharynx, and fauces, which predispose the patient to the 
primary attack, are present, there will be greater difficulty in effecting 
a favorable termination of the disease, and when it seems to have been 
cured there may be recurrences. 

The duration of the acute type varies from one to six weeks, although 
in some cases it may be aborted in one or two days. The pain, which is 
one of the first symptoms to appear, is also one of the first to subside. 
Then the redness of the drumhead and the swelling of the mucosa, 
after which the hearing power begins to return. Later the tinnitus 
passes away. This symptom, however, often remains for several weeks, 
and in those cases which merge into the chronic form it may become a 
permanent symptom. 

Treatment. — There are several influences to be considered in the 
treatment of acute catarrhal middle ear inflammation, as the causes are 
various and sometimes quite complicated. We are often called upon to 
relieve the patient of the pain or even of the acute inflammatory process, 
but we are not so frequently asked to treat the conditions which, if 
removed, would prevent a recurrence of the disease. This cannot be done 
without giving attention to the nasal, epipharyngeal, and faucial condi- 



714 THE EAR 

tions which are largely responsible for the middle-ear inflammation. 
The treatment should, therefore, be addressed to the relief of the acute 
inflammatory process in the middle ear and the upper respiratory 
tract in general, as well as to the complete removal of the morbid condi- 
tions of the nose, epipharynx, and fauces. The first duty of the attend- 
ing physician is to allay the pain as quickly as possible. 

General or hygienic treatment should first of all be considered, as 
the proper care of the patient will largely influence the progress of the 
disease. He should be kept in the house during the acute stage, and if 
fever is present he should remain in bed. The room should be well 
ventilated and exposed to sunshine. His food should be simple and 
nourishing, such as is usually given to bedridden patients. The bowels 
should be regulated with calomel and saline cathartics, while alcoholic 
beverages and tobacco should be forbidden. A light pledget of cotton 
should be kept in the external meatus to protect the drumhead and the 
middle ear from air currents. 

Pain, being the most prominent subjective symptom, should receive 
appropriate treatment at once. It is often so excruciating that the patient 
is very restless. A mixture of equal parts of carbolic acid, glycerin, and 
the hydrochlorate of cocaine may be dropped into the external meatus, 
where it will, in most cases, afford relief within a few minutes. A mix- 
ture of laudanum and oil in the external meatus is not of very much 
value. The mixture is usually warmed in a teaspoon before use, and 
if there is any virtue in it at all, it is due to the warmth or protection it 
affords to the exposed and inflamed membrane. 

Another remedy of value for the relief of pain as well as of the con- 
gestion is a 12 per cent, solution of carbolic acid in glycerin (Andrews). 
While this solution does not have as great anesthetic power as the one 
above recommended, it nevertheless aids materially in allaying the pain. 

The author has often used the fumes of chloroform as a relief. There 
are a number of ways in which this may be applied, perhaps most 
conveniently with a pipe, in the bowl of which there is a small piece 
of cotton upon which a few minims of chloroform are dropped. The 
stem of the pipe should be placed to the meatus, while the bowl is placed 
to the mouth of the operator. 

The fumes thus gently blown into the external auditory meatus 
usually afford relief in a very few seconds or minutes. Leeches applied 
to the tragus, or posterior to the auricle, also relieve the pain and promote 
the reaction of inflammation. 

Cold may be applied over the ear, although the effect is neither good 
nor pronounced. Hovell recommends the use of blisters by means of 
plasters over the mastoid process, though they are liable to produce 
ugly sores. Their value is due to the fact that they promote the reaction 
of inflammation, but there are other remedies which are more efficacious 
and which do no harm, such as the leukodescent light from a 500 candle- 
power lamp. 

Tympanic Inflation. — During the last few years the literature has 
shown a partiality for the use of glycerin and carbolic acid for the cure 



ACUTE CATARRHAL OTITIS MEDIA 715 

of acute middle-ear inflammations. The remedy is a valuable one, but 
it does not meet all the indications, especially those which arise from 
the great tumefaction and adhesive processes. It is important that 
tympanic inflation be performed at frequent intervals, as the increase 
of the air pressure within the middle ear separates the inflamed surfaces. 
In this way adhesions are prevented, or, if formed, are broken down 
and a long train of symptoms and impairment of the auditory function, 
so often seen in the dry or adhesive types of chronic ear disease, are 
averted. The inflation also serves a very useful purpose in freeing the 
tympanic cavity from secretions and in maintaining the patency of the 
Eustachian tubes. 

If the drumhead is very red and swollen, and there is great pain, the 
air douche should be used with great caution, as there is danger of 
perforation. Inflation should be chiefly limited to the second stage 
of the disease, and should be performed at frequent intervals. The 
patient should be provided with the Politzer air bag and instructed 
in its use. The frequency with which it should be used depends upon 
the rapidity with which the secretions are formed. In ordinary cases 
it should be used at intervals of one to three hours. In this way the 
tympanic cavity and Eustachian tubes are kept free from secretions. 
The hyperemia is reduced by the increased air pressure, and the adhe- 
sions between the ossicles and tympanic walls are prevented. 

Inflation is most effective when performed through the Eustachian 
catheter, but this, of course, can only be done by the attending physician. 
The mucous membrane of the tube is usually quite swollen, and inflation 
difficult to accomplish on this account. Dr. Sidney Yankauer advises 
the preliminary use of cocaine to reduce the swelling. He first passes 
a standard catheter of virgin silver, through which he introduces an 
applicator wound with cotton saturated with a 5 per cent, solution of 
cocaine. The applicator is introduced as far as the isthmus or further, 
say 20 to 25 mm. beyond the tip of the catheter. It is advanced by 
stages every few minutes as the swelling subsides. A 25 per cent, 
solution of argyrol is then applied in the same manner. A single treat- 
ment, if applied before the membrana tympani bulges, or pus forms, is 
often followed by an immediate cessation of the middle-ear inflammation. 
If this does not occur the tube is rendered more patent and inflation can 
be effectively performed. 

Leeching over the mastoid process and in front of the tragus is often 
attended with prompt and marked improvement. There is no other 
remedial measure that acts as promptly, and it would be a distinct 
advantage if leeches were used more frequently than they are at present. 
The artificial leech, as shown in Figs. 408 and 409, may be used instead 
of live leeches if desired. 

Pneumomassage is a valuable adjunct to the treatment of the later 
stages of acute inflammations of the middle ear. During the acute or 
first stage it cannot be used on account of the pain and great swelling 
present, but later it is valuable, as it lessens the vascular and lymphatic 
engorgement of the tissues and prevents ankylosis of the ossicles. The 



716 



THE EAR 



form of pneumomassage best adapted for use in these cases, at least 
in the secondary stage, is alternating compression and rarefaction of 



Fig. 408 




The application of the artificial leech to the mastoid process. The cord is drawn, thus rapidly 
rotating the circular knife applied to the skin of the mastoid process. 

Fig. 409 




The exhaust pump withdrawing blood through the circular incision. 

the air in the external meatus. With the Victor massage apparatus and 
the Pynchon modification of the pump (Fig. 13) any variety or character 



ACUTE INFLAMMATION OF THE EXTERNAL ATTIC 111 

of compression and rarefaction that may be desired can be produced. 
Care should be taken to adjust the piston to such a length of stroke 
as will cause no pain, as otherwise it may increase the inflammatory 
process or rupture the drumhead. The principle is the same as that 
relating to the use of massage in any other part of the body — namely, 
that it should be used with such force as not to produce contusion or 
injury to the tissues. If such an instrument is not available, Siegle's 
otoscope (Fig. 410) or the Delstanche masseur (Fig. 12) may be used. 
If neither of these are at hand, a simple rubber tube with a suitable 
metal tip, through which alternating compression and rarefaction may 
be produced with the mouth, will serve the purpose. These instruments 
have the advantage of being under the perfect control of the operator, 
while they have the disadvantage of imposing upon him the necessity 
of administering the treatment from one to fifteen minutes, as the case 
may require. Some otologists regard the massage machines, which are 
propelled by an electric motor, as being impressive pieces of machinery, 
which have but little actual value as therapeutic agents. The author's 
years of actual experience, however, with both kinds of apparatus has 

Fig. 410 




Siegle's otoscope. 

proved that better results are obtained by the judicious use of the 
so-called " machines" than is possible v/ith the hand devices. However, 
the hand instruments are especially well adapted for use in acute catar- 
rhal cases, as pneumomassage is not usually applied for long periods 
at any one time. Pneumomassage is of little value in well-advanced 
adhesive processes, and in selected cases the only treatment is surgical. 

ACUTE INFLAMMATION OF THE EXTERNAL ATTIC OF THE 
TYMPANIC CAVITY (POLITZER) 

The external attic is sometimes the seat of a circumscribed acute 
inflammation. The exudate is thrown out into Prussak's space (Fig. 
375) and partly into the spaces formed by the folds of mucous membrane 
between the malleo-incudal body and the external tympanic wall. 

The disease is characterized by slight pain and deafness, with a tumor 
or blister-like formation on the anterior portion of Shrapnell's mem- 
brane (membrana flaccida); or if the posterior spaces are involved, the 
projection forms upon the posterior portion of the flaccid membrane. 



718 THE EAR 

Etiology. — The exciting cause of this rather rare condition is the same 
as in acute otitis media — namely, the specific bacteria of exanthematous 
fevers, epipharyngitis, and influenza. Sea bathing and cold solutions 
in the external canal act as predisposing causes. It is probable that 
the infection usually reaches Prussak's space through the Eustachian 
tube, although it is possible for it to pass through the Rivinian 
foramen. 

Symptoms. — In the mild form there is a feeling of fulness in the middle 
ear, slight pain, deafness, and tinnitus. The membrana flaccida is red- 
dened and bulging, or it may be yellow at its prominent portion. The 
upper wall of the meatus near the drumhead is red and slightly swollen. 
The membrana tensa usually appears normal. The process may run its 
course in a few days. 

In the severe form the reactive symptoms are more pronounced, the 
hearing being temporarily more disturbed, although there is usually no 
permanent loss of hearing. The membrana flaccida is much more bulg- 
ing, often completely covering the short process and handle of the malleus. 
The course in the severe form is prolonged, though it may end in com- 
plete recovery. 

Treatment. — The treatment is the same as for acute otitis media and 
acute suppurative otitis media, except there is no need for tympanic 
inflation, as there is no deafness from swelling of the mucosa of the 
middle ear and Eustachian tube, and the tension of the membrana 
tensa and ossicles is not disturbed. 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 

This disease is characterized by intermittent or remittent deafness 
and tinnitus aurium. It may follow acute catarrhal otitis media, or it 
may come on without any previous history of acute disease. In some 
cases deafness is progressive, while in others it extends by leaps and 
bounds. The patient often makes the statement that he hears very well 
until after exposure, after which he is much more deaf. The acuity of 
his hearing is usually less during the damp, cool weather of late autumn 
and early spring. 

Etiology. — The etiology as given under Acute Catarrhal Otitis 
Media in a large measure applies to this disease. Therefore, a detailed 
statement is not given in this connection. It is sufficient to state that 
in most instances the chronic disease is an immediate result of the 
acute inflammation. This is especially true in those cases which are 
not treated early or in an appropriate manner. It is also especially 
liable to follow the acute type in those cases in which there has been 
previous chronic rhinitis, sinuitis, epipharyngitis, and obstruction of the 
Eustachian tubes. The obstruction of the tubes by adenoids, epipharyn- 
geal catarrh, nasal and accessory sinus disease, etc., undoubtedly forms 
one of the chief factors in the production of the disease. (See Etiology, 
Acute Catarrhal Otitis Media.) 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 719 

Symptoms. — Subjective Symptoms. — The chief subjective symptoms 
are deafness and tinnitus aurium. In addition to this, there is a feeling 
of fulness in the ears. Giddiness is present in a certain number of cases, 
but is by no means a constant symptom. 

Deafness. — This is the chief symptom of the disease, and is usually 
the one which leads the patient to seek relief. In quite a number of cases, 
however, the tinnitus is so much more annoying than the deafness that 
relief is sought on this account. The deafness may at first be so slight 
and insidious in its progress that the patient is unconscious that his 
hearing is defective. He explains his inability to understand what is said 
to him by the slipshod way in which he is spoken to. It is not uncommon 
for such patients to feel offended when it is intimated that they do not 
hear well. They are very apt to reply that they can hear when they 
are spoken to in the proper manner. Later they notice slight subjective 
noises, after which it is only a question of a few months until they be- 
come conscious that their hearing is defective. In some subjects, how- 
ever, the progress is not so insidious as that just described. On the con- 
trary, it may be very rapid, then after a time seemingly remain stationary 
for months or years. The deafness may again suddenly become worse, 
and so continue throughout life. The rapid progress made is not indica- 
tive of the severity of the inflammatory process, but rather points to 
the fact that certain vital parts have become involved, thereby limiting the 
sound-conducting function of the auditory apparatus. If the changes 
which take place in the middle ear are limited to the mucosa of the tym- 
panic cavity, the deafness is slighter and less rapid in its progress; 
whereas, if the ossicular chain and the round or the oval windows are 
involved in a marked degree, the deafness comes on suddenly and is 
more pronounced in character. It is important to bear this in mind, 
as otherwise it is not possible to understand why in one case of simple 
chronic catarrhal otitis media there is such slight deafness, while in 
another there is marked and sudden increase in the deafness. 

Tinnitus aurium is a symptom which is almost constantly present 
in greater or less degree, causing the patients much annoyance. Their 
sleep and rest at night are interfered with. They sometimes become 
nervous and hysterical, and if relief cannot be afforded are apt to become 
morose. The noises in the head assume almost any variety of sounds or 
tones, ranging from simple pulsating murmurs to thundering noises, or 
reports like the shot of a pistol or cannon. In many cases they are 
of a whistling or singing character, while in others there is a buzzing, 
or dripping sound. They may be musical or simply noise. They may 
be mild or very intense. They may be constant, intermittent, or re- 
current. It is doubtful if the noises in simple catarrhal otitis media 
ever assume the form of spoken language. Those who seem to hear 
voices and to receive messages and revelations probably have a central 
lesion of the cortex. The brain may otherwise be practically normal, 
so that the psychological phenomena referred to the organ of hearing 
may be the only evidence that the patient has departed from the normal 
mental state. The case of Joan of Arc, which has excited so much 
historic and romantic interest, possibly belonged to this class. 



720 THE EAR 

In some cases the tinnitus is synchronous with the heart beats, while 
in others it is very irregular in rhythm. Various explanations have been 
given to account for those cases in which the noises are synchronous with 
the cardiac pulsations, none of which seems to explain them satisfactorily. 
The most probable explanation is that in some way or other the vibratory 
thrill of the arteries of the tympanum is imparted to the membrana 
tympani and the ossicular chain in such a way as to be transmitted to the 
labyrinth, from whence the sensation is conveyed through the auditory 
nerve to the brain centre, where it is appreciated as sound. The tin- 
nitus may be very high or low in pitch, and in either case is indicative 
of an advanced stage of the disease. If, on the other hand, it is medium 
in pitch, a less advanced stage is indicated. The state of the general 
health very materially influences the degree and the character of the 
noises. When the patient is fatigued or is affected by some disease 
which lowers his vitality, they are worse. I have seen patients who were 
the subjects of neurasthenia, in whom the pulsating noises were very 
pronounced. Some of these patients did not have ear disease, the pul- 
sating tinnitus being only one of the symptoms peculiar to their nervous 
and anemic condition. In others, who were subject to catarrhal otitis 
media, the tinnitus was very much aggravated by the neurasthenia. 
The excessive use of alcohol and tobacco increases the intensity of the 
noises, and may even cause pulsating tinnitus, synchronous with the 
cardiac pulsations, even in persons who are not subject to otitis media. 

Autophony consists of a vibration and echo-like reproduction of the 
patient's own voice. This symptom is sometimes present in the moist, 
but more particularly in the dry type of catarrh. It is most com- 
monly found in those cases in which there is an undue patency of the 
Eustachian tube. 

The paracusis of Willis, or "paracusis Willisii," is a symptom which 
is present in well-advanced cases. When present, it is an unfavorable 
sign, and should lead to a very guarded prognosis, as a more careful 
examination may reveal the presence of hyperostosis (spongifying) of 
the bony capsule of the labyrinth in addition to the middle-ear disease. 
Paracusis Willisii consists of an ability to hear better in the presence of 
noises than in a quiet place. Thus patients will hear better in a street 
car or train than they do in a quiet country home. It is a probable 
indication that the mobility of the ossicles is interfered with by ankylosis 
or adhesive processes, or the swelling of the mucous membrane of the 
tympanic walls, or it may point to hyperostosis of the bony capsule of 
the labyrinth. 

Objective Symptoms. — The drumhead should be examined with refer- 
ence to its position, color, lustre, and reflection of light. In infants its 
position is normally at a very obtuse angle to the superior wall of the 
meatus, while in adults the obtuseness of the angle is much less pro- 
nounced. In other words, in adults the drumhead is more nearly at right 
angles to the axis of the external meatus than it is in very young children. 
In infants it is so nearly parallel with the superior wall of the meatus 
that it seems to be a continuation of it. As the tympanic ring develops 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 



721 



Fig. 411 



it rapidly assumes a more erect position, until it finally assumes that 
which is maintained throughout adult life. Its position will, therefore, 
depend upon the age of the patient and upon the completeness with 
which development has taken place. 

If the Eustachian tube is closed for any reason, the drumhead will be 
drawn inward or retracted. This gives rise to a change in the contour 
of the drumhead, and consequently modifies the reflections from its sur- 
face. The cone of light which is normally present with the apex toward 
the lower end of the handle of the malleus, while its base is directed 
downward and forward toward the periphery, will either diminish 
in size, break into one or two whitish spots, or entirely disappear. 
These changes are, in most cases, indicative of retraction of the drum- 
head. If there are adhesions binding the membrana tympani to the 
promontory or other portions of the inner tympanic wall, its surface will 
present an uneven appearance, especially after inflation. At the points of 
adhesion it will appear whitish in color, whereas in the non-adherent 
portions there may be a slight reddish color, due to the reflection of 
light from the red mucous membrane of the inner tympanic wall. 

The color of the drumhead has been variously described as of a pearl- 
gray, pinkish-gray, bluish-gray, or yellowish-gray membrane. Some of 
these observations have been made upon cadavers in which the 
normal colors were not present. By the 
use of such lights as are now at the com- 
mand of most practitioners, the healthy 
membrane uniformly presents a pearl- 
gray color, with here and there a slight 
admixture of orange and purple. The 
orange is due to the red reflex of the 
inner tympanic wall, and is now regarded 
as a sign of spongifying. 

Calcareous spots are sometimes found 
on the drumhead, even when there is no 
history of a previous suppurative process, 
and are undoubtedly the remnants of 
former inflammatory processes. 

In the normal drumhead there is a dis- 
tinct luminous lustre (Fig. 411), which is 
so modified in chronic catarrhal otitis 
media as to materially lessen its smooth- 
ness and brilliancy. The membrane ap- 
pears whitish and velvety in texture in 
proportion to the amount of thickening it has undergone. The redness 
and the pinkish-gray color disappear because the vascularity and 
transparency of the drumhead are diminished. 

The appearance of the drumhead may be modified by the presence of 
tympanic secretion. The dark line spoken of under Symptoms of Acute 
Otitis Media, which marks the upper limit of the secretion, may be 
present in these cases. Unless the thickening of the drumhead is so pro 

46 




A normal membrana tympani of 
the right ear as viewed through a 
speculum. 



722 THE EAR 

nounced as to interfere with its transparency, the bubbles of air spoken 
of in the same connection may also be seen. The presence of an appre- 
ciable amount of mucus in the middle ear is usually a sign of a subacute 
attack, but the drumhead may be so thickened that it is not easy to 
discern it. The opacity of the mucus increases with its viscidity, hence 
some estimate may be made by observing the character of the secretion 
present. In those cases in which the drumhead is atrophied in circum- 
scribed areas, the secretion may be clearly seen at these points, while at 
the more opaque and thickened areas its presence cannot be detected. 
If there is a large quantity of mucus in the middle ear, the drumhead 
may bulge outward in its entirety if non-adherent, or in part if there 
are adhesions (Fig. 412). 

Prognosis. — The curability of chronic otitis media is somewhat in 
proportion to its chronicity and the pathological changes in the essential 
structures of the tympanic cavity. If the disease is of recent occurrence 
and the morbid changes are slight, the prognosis is quite favorable. If 
the disease is of long standing and pronounced degenerative changes 
in the mucous membrane covering the ossicles or the membrana tym- 
pani have occurred, the prognosis as to the restoration of hearing is 
not good. 

Fig. 412 Fig. 413 





Adhesive retractions (a, a) of the Adhesive processes affecting the 

membrana tympani. membrana tympani. 

Treatment. — The treatment should take two general factors into 
account, namely, the etiology and the pathological changes present. If 
the chronic disease is the offspring of an acute catarrhal process, the causes 
of the acute disease should be determined and eradicated if possible. 
If the patient has been subject to either of the forms of rhinitis or sinuitis, 
he should be treated accordingly. Ethmoiditis and sphenoiditis are 
particularly responsible for otitis media, and in a number of cases the 
chief cause. Too little attention has been given to these cavities in the 
treatment of ear disease. Appropriate treatment, surgical or otherwise, 
addressed to the sinuses, if given early, speedily relieves the ear disease. 
The symptoms of mild chronic ethmoiditis and sphenoiditis are not 
so obvious as to attract the attention of the physician unless he has had 
unusual opportunities for making such observations. The patient, 
perhaps, only complains of a ''dropping" into the throat. An examina- 
tion of the epipharynx and posterior choanse may show a mucopuru- 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 723 

lent secretion flowing over the posterior ends of the middle turbinals 
on to the posterior wall of the epipharynx. Anterior rhinoscopy shows 
the middle turbinal closely approximated to the septum. The divulsion 
of the middle turbinal away from the septum, or its partial or complete 
removal, will often exert a very favorable influence upon the course of 
the aural disease. In some cases, it may be necessary to make a total 
exenteration of the ethmoidal cells and to remove the anterior wall of 
the sphenoidal sinus. 

If the ear disease is due to tonsillar disease, total ablation of the 
tonsil with its capsule intact is the best method of procedure. 

Adenoids and inflammatory processes of the epipharyngeal mucous 
membrane, if present, should be treated. The presence of adenoids often 
perpetuates a chronic epipharyngitis, hence their removal exerts a favor- 
able effect. As the pharyngeal inflammation extends by continuity 
of tissue to the Eustachian tube and middle ear, it is obvious that the 
removal of the adenoids or their remnants will exert a very favorable 
influence upon the course of the ear disease. McBride and Logan 
Turner have shown that adenoids often persist in adults, undiminished 
in size. In every case of chronic catarrhal otitis media, the otologist 
should examine the epipharynx, and if adenoids are present, they should 
be removed, even though they do not obstruct the nose. 

When the structures adjacent to the Eustachian tube have been freed 
from morbid processes, the ear may be treated for the removal of the 
local morbid lesions and to restore the equilibrium of tension between 
the drumhead ossicles and the labyrinthine fluid. 

The tympanic cavity should be inflated for three purposes, namely: 
(a) To force the secretions from the tympanic cavity and Eustachian 
tube; (b) to restore the equilibrium of air pressure on the two surfaces 
of the membrana tympani ; and (c) to improve the arterial and lymphatic 
circulation of the lining mucous membrane. (See Principles of Tym- 
panic Inflation and Methods of Tympanic Inflation.) 

The air should be rarefied in the external meatus with Delstanche's 
rarefacteur after each inflation, as this increases the passive hyperemia 
of the inflamed membrane and promotes the absorption of the inflam- 
matory exudates. It also reduces the annoying tinnitus usually present 
in this disease. 

The mechanical removal of the secretions from the middle ear may be 
accomplished by paracentesis (Schwartze) or incision of the drumhead 
and by suction applied to the external meatus. This procedure is only 
indicated when the secretions are so heavy and tenacious as to resist being 
discharged through the Eustachian tube, or when the tube is obstructed 
by disease. The incision should be long and curved (see Incision of 
the Membrana Tympani), as in acute suppurative otitis media before 
perforation. 

Even then the secretions will not appear in the meatus for several 
minutes or hours, unless the middle ear is forcibly inflated or suction is 
applied to the meatus. The meatus should be lightly packed with a strip 
of gauze for a few hours, at the end of which time it will be saturated 



724 THE EAR 

with the secretion. After thoroughly cleansing the meatus with a cotton- 
wound applicator, it should be refilled with gauze. The incision usually 
closes in from one to three days, and should be repeated if marked 
bulging of the membrana tympani reappears. 

When the secretions are more serous in character, drainage is facili- 
tated, as suggested by Politzer, by having the patient take a swallow of 
water in his mouth, then inclining his head well forward and somewhat 
toward the opposite side, thereby causing the axis of the Eustachian 
tube to stand perpendicular to the plane of the earth. The patient's 
head should be held in this position for two or three minutes, to allow 
the secretions in the middle ear to gravitate to the tympanic end of the 
Eustachian tube. At' the end of this time he should swallow the water 
held in his mouth, thus opening the pharyngeal end of the tube and 
allowing the secretions to flow into the pharynx. As Politzer says, shortly 
after this procedure the membrana tympani presents a grayish color, 
whereas it was yellowish in color. 

The passive hyperemia of the mucous membrane of the Eustachian 
tube gradually subsides during the treatment by inflation, and the 
patency of the tube is gradually restored. The secretions also diminish 
in quantity and in consistency, and the tube becomes adequate to carry 
on its drainage and ventilating functions. 

In rare instances the swelling of the tube persists, and it may become 
necessary to make local applications of weak zinc, silver, ammonium 
chloride, ol. eucalyptus, and the vapors of menthol to the tube. Gener- 
ally speaking, these remedies are of slight value, a better procedure 
being the administration of hepatic and saline aperients. Mechanical 
vibrations behind the angle of the inferior maxilla are very useful in 
opening the Eustachian tube when it resists the usual methods. 

A. H. Buck has recommended the introduction of medicated bougies. 
Politzer uses a small violin string cut into suitable lengths for this pur- 
pose. They are soaked in a saturated solution of the nitrate of silver, 
dried, and introduced through a catheter as far as the isthmus tubse, and 
left in position for from three to five minutes. Three to four applications 
often open the tubes. 

Sidney Yankauer recommends the use of sounds daily through a 
standard Eustachian catheter if a firm stricture or obstruction is present. 
After a few days a larger sound may be introduced. The sound should 
be left in the tube for fifteen minutes. 

ADHESIVE PROCESSES IN THE MIDDLE EAR 

Synonyms. — Sclerosis of the middle ear; otitis media catarrhalis 
chronica; dry catarrh of the middle ear; otitis media catarrhalis sicca; 
otitis media sclerotica; proliferous inflammation of the middle ear. 

Etiology — The causes of adhesive processes in the middle ear are 
not fully understood. It is probable that several conditions are included 
under this title. Exudative catarrhs of the middle ear are often attended 
by the formation of adhesive processes, and these sometimes appear 



ADHESIVE PROCESSES IN THE MIDDLE EAR 725 

without being preceded by a secretive or exudative catarrhal inflamma- 
tion. The trophic centres or tracts seem to be at fault, and the onset 
and progress of the disease are insidious and result in pronounced 
deafness. The membranous labyrinth is often involved, probably from 
the same trophic influences. The mucous membrane around the oval 
window is especially affected, and the cicatricial contraction of the 
fibrous bands often fixes the stapes firmly in the window. Atrophy 
and fatty and colloidal degeneration of the labyrinth often occur simul- 
taneously with or precede the sclerotic processes in the middle ear. 
The adhesive processes resulting from exudative catarrh of the middle 
ear are not attended with such pronounced deafness, and are marked by 
decided symptoms even in the early stages. In the trophic or insidious 
form, symptoms do not usually manifest themselves until the disease 
is well advanced. 

The etiology may be summarized as follows : 

(a) Exudative or moist catarrh of the middle ear. There is some 
doubt as to the causative influence, as in children in whom it most 
frequently occurs the adhesive processes are rarely found. 

(6) Trophic disturbances affecting either the middle ear or labyrinth. 
It appears in some cases to affect the labyrinth first and extend to the 
middle ear. Probably both the middle ear and labyrinth are affected 
at the same time, although the symptoms may become manifest in one 
earlier than in the other. It is also quite probable that hyperostosis 
or spongifying of the bony capsule of the labyrinth is mistaken for an 
adhesive process, though the normal appearance of the drumhead should 
obviate such a mistake in diagnosis. 

Pathology. — The adhesive processes may be classified as either 
diffused or circumscribed. The diffused type usually arises from an exu- 
dative chronic catarrh; the circumscribed type from trophic disturbances. 

According to Politzer, "the structural changes in the mucous mem- 
brane consist in partial or total transformation of the new-formed round 
cells into fibrous connective tissue, interstitial hypertrophy of the mucous 
membrane with . retrograde metamorphosis of the new-formed tissue, 
shrinking, sclerosis, atrophy, and calcification/' 

In those cases in which the secretions are still abundant, the mucous 
membrane is hyperemic, spongy, or gelatinous, and yellow or bluish red 
in color. The surface is uneven and ragged in appearance. 

After the moist stage has subsided, the membrane becomes smooth, 
very thick, and firmly attached. 

In the diffused or insidious type, the changes seem to proceed from the 
periosteum to the epithelial surface of the membrane. The favorite 
location for the adhesive process in these cases is about the oval window 
(spongifying?). The general appearance on inspection through an open- 
ing in the drumhead shows very little evidence of the true condition. The 
contraction and calcification take place in the deeper portions of the 
mucosa and fix the foot plate of the stapes in the oval window. 

In another class of cases, numerous fibrous bands form in the middle 
ear. They may extend from the ossicles to the walls of the tympanum or 



726 THE EAR 

from ossicle to ossicle; or they may extend from the walls to the drum- 
head. The ossicles are thus bound together, and the drumhead is drawn 
by contracting fibrous bands to the fixed walls of the middle ear (Fig. 
413). The normal tension of the ossicular chain and drumhead is thereby 
unbalanced, and serious disturbance of hearing occurs. 

In fetal life, bands or folds of mucous membrane exist in the same 
places often occupied by fibrous formations in the adhesive process. 
They may be, therefore, only perversions of an earlier embryonal forma- 
tion. According to Toynbee and von Troltsch, the bands are sometimes 
transformed by calcareous deposits into bone-like processes. 

In addition to the foregoing changes, the articulations of the ossicles 
may be ankylosed by fibrous formations or by the deposit of lime salts. 
In either event, the vibratory function of the chain of ossicles is impaired. 

The mucous membrane of the entire attic in rare cases undergoes 
calcification, and a partial or complete obliteration of the attic results. 

The changes in the Eustachian tubes are largely dependent upon 
whether the middle-ear disease is of the diffused or the circumscribed 
variety. In the diffused type, the tube is similarly affected, while in 
the trophic type, it is usually normal. The lumen is obstructed in the 
diffused variety, while it is unaffected in the circumscribed type. 

Both ears are affected except in rare cases. This, together with the fact 
that it rarely occurs in children, in whom the moist or exudative catarrhs 
are most common, rather discredits exudative catarrh as the cause. When 
it occurs in children, it is usually easy to trace it to disturbances of nutri- 
tion, scrofula, etc. 

Symptoms. — It is convenient to study the symptoms under the (a) 
drumhead, (b) the Eustachian tubes, and (c) the subjective symptoms. 

(a) The drumhead is thickened, lustreless, and opaque. Areas of 
opacities more or less sharply defined may sometimes be seen. In some 
cases they are sharply defined, and appear as chalky white deposits, 
while in others they merge into the surrounding tissue with ill-defined 
borders. The spaces between the whitish deposits appear dark or 
bluish in color. 

The handle of the malleus appears less distinct and wider than normal 
on account of the thickened condition of the drumhead. The cone of 
light is shortened, irregular, or broken. The handle of the malleus 
is drawn inward and backward, and is, therefore, foreshortened. 

The adhesive bands may be attached to the drumhead and cause cir- 
cumscribed retractions (Fig. 412). The retracted areas may also be due 
to atrophy or to direct adhesions of the drumhead to the inner tympanic 
wall. They appear as rounded, oval, or irregular depressions (Fig. 413). 

Schwartze called attention to a distinct reddish glimmer around the 
umbo as indicating a circumscribed inflammation (insidious type) 
around the oval window. In these cases the drumhead is usually normal, 
although it is occasionally opaque or atrophic. Such cases are now 
generally recognized as hyperostosis of the bony capsule of the labyrinth. 

The external meatus is usually devoid of cerumen, although it may be 
covered with a dense brown secretion. 



ADHESIVE PROCESSES IN THE MIDDLE EAR 727 

(b) In the diffused variety the Eustachian tubes may be more or less 
obstructed by fibrous formations in their lumens. In the circumscribed 
variety they are usually normal. 

(c) The subjective symptoms vary according to the degree of involve- 
ment of the middle ear and labyrinth. They also vary with the location 
and character of the lesion. 

Perhaps the most common and pronounced subjective symptom is 
tinnitus. If the disease is well advanced it is continuous, although its 
intensity varies with the atmospheric conditions and constitutional vigor 
of the patient. If tired, worried, or weakened from the excessive use of 
alcoholic beverages, or illness, it becomes more pronounced. The noises 
vary in character and intensity even in the same individual. 

Disturbances of hearing may appear simultaneously with the tinnitus, 
although the subjective noises usually appear first. The noises some- 
times increase with the deafness, although in many cases they gradually 
diminish and cease altogether with complete deafness. 

Pain is rarely present, although hyperesthesia acoustica is often a 
prominent symptom in the early stage of the disease. It is especially 
marked in the presence of shrill tones and loud speech. 

More or less giddiness and fulness in the head are experienced in the 
cases in which there is continuous tinnitus. In some cases the Meniere 
group of symptoms is present, especially when there is a sudden increase 
in the deafness. It is probably due to a rapid deposit of an exudate in 
the labyrinth. The giddiness is sometimes persistent, while in others it 
gradually disappears without apparent damage. Aprosexia or difficulty 
in fixing the attention is sometimes complained of. 

The hearing is disturbed in proportion to the interference with sound 
waves passing through the drumhead and ossicles and the degree of 
pathological changes in the labyrinth. The patient hears at a greater 
distance at one time than another, although the variation is not as great 
as is observed in ordinary catarrhal otitis media with secretion. The 
condition of the patient influences the hearing in a marked degree. He 
hears better in the morning when vigorous than he does toward evening 
when weary. Mastication of the food temporarily increases the deafness. 

Hearing for speech may be very poor, while the finest variations in 
music may be distinguished, or the falling of a small instrument may be 
distinctly heard (Politzer). 

Paracusis Willisii, or ability to hear better in a noisy place, as in a 
street car, is quite characteristic of this affection. It is important to 
ascertain in every case whether or not this symptom is present, as it gives 
a fair indication as to the prognosis of the disease. It should not be 
assumed, however, that the patient cannot be benefited by treatment 
because this symptom is present. The ordinary treatment by inflations 
and massage will usually fail to afford relief, but more radical measures, 
to be described, will in rare instances prove effective. 

The Course of the Disease. — The course of the disease is progressive, 
although it is not steady in its advancement. It rarely progresses by 
gradual increase in the deafness, but goes by leaps and bounds. It often 



728 THE EAR 

remains stationary for years and then suddenly becomes worse. It is 
always progressive, as it is due to degenerative pathological changes in 
tissues, as contraction, calcification, and ossification. These conditions 
develop slowly, on account of the nature of the pathological process. 
They progress by leaps because the changes may involve portions 
of the tissue but little concerned in the function of hearing, until finally 
it encroaches upon tissue intimately concerned in audition, and hearing 
suddenly becomes impaired. This does not necessarily mean that 
the pathological process has suddenly increased, but that it has invaded 
the functionating tissue. The disease rarely causes complete deafness. 

In the insidious or trophic type of the disease, persistent tinnitus often 
of a most aggravated character, may exist for years without deafness. 
The trophic interstitial changes are chiefly about the fenestra of the vesti- 
bule (oval window). Finally, the foot plate of the stapes is ankylosed, 
and deafness becomes a pronounced symptom. These cases are often 
mistaken for nervous tinnitus until the deafness sets in. 

Politzer says that the greater number of cases in which ankylosis of 
the stapes was observed post mortem, he found from the history of the 
patient that the decrease of hearing occurred after the existence of 
subjective noises for ten or fifteen years, and the progressive increase 
of deafness was very gradual. In these cases there was generally a 
marked negative Rhine, with sometimes lengthened and sometimes 
diminished duration of perception through the cranial bones, the latter, 
especially when the disease had existed for a long time, and in old 
age. 

When unilateral adhesive inflammation has existed for a long time and 
the other ear subsequently becomes involved, the progress in this ear is 
quite rapid, in contradistinction to the progress in bilateral involvement. 

In rare cases a change for the better takes place spontaneously. This 
may be permanent, or it may be followed by a sudden increase of the 
deafness and tinnitus. 

Diagnosis. — (a) Thickening, contractions, and chalky deposits in the 
drumhead. 

(6) The drumhead often presents a ground-glass appearance. 

(c) Marked negative Rhine with loss of hearing for low tones shows 
middle-ear involvement. 

(d) Adhesive bands may be present, and the Rinne test does not show 
a marked negative result. Labyrinthine involvement probably present. 

(e) High tones are heard better than low ones. In some cases, how- 
ever, there is loss of hearing for high tones, thereby indicating labyrinthine 
involvement. 

(j) By the use of Siegle's otoscope (Fig. 410), the drumhead may be 
made to move back and forth under alternate suction and pressure. If 
adhesions are present, the drumhead remains fixed at these points. 

(g) Inflation of the middle ear causes the thin portions of the drum- 
head, when present, to bulge outward like bubbles. Improvement of 
hearing usually lasts while the bubbles remain inflated. The adherent 
parts remain unmoved under inflation. 



ADHESIVE PROCESSES IN THE MIDDLE EAR 729 

(h) Marked movement of the handle of the malleus precludes anky- 
losis of the malleus and incus. Ankylosis of the incus diminishes the 
movement of the malleus. 

Prognosis. — The prognosis will be studied under two headings, 
namely: (1) The more favorable signs, and (2) the unfavorable signs. 

The More Favorable Signs. — (a) Fibrous bands following the secre- 
tive form of catarrh are more favorable than those from the insidious 
type which are more often associated with labyrinthine disease, (b) If 
the case has not progressed to a high degree of deafness, the prognosis 
is more favorable, (c) If subjective noises have been but little mani- 
fested, the prognosis is more favorable, (d) Good bone conduction is 
also a favorable sign, (e) Improvement in hearing and tinnitus after 
inflation is a good sign. 

The Unfavorable Signs. — (a) Early deafness, (b) Slight or no increase 
in the hearing distance after inflation of the middle ear. (c) Diminished 
bone conduction, (d) Advanced age. (e) Constitutional ailments. 
(J) Heredity. 

It should be said that complete restoration of hearing is not possible 
in any of the cases, as the changes have been of long duration and are 
^retrograde in character. Indeed, few cases are benefited by treat- 
ment. 

Treatment. — This is most conveniently divided into (a) non-surgical 
and (b) surgical treatment. The purpose of treatment should be three- 
fold, namely, to improve the hearing, mitigate the tormenting subjective 
noises, and check the progress of the disease. 

Non-surgical Treatment. — The form of treatment most in vogue among 
physicians in America is inflation of the middle ear, by either the Politzer 
method or through the Eustachian catheter. Politzer claims better 
results by his method than by the use of the catheter. This is probably 
due to the fact that the Eustachian tubes are usually quite patent and 
easily inflated by the bag. Those cases which show improvement after 
the use of the air-bag are more favorable for treatment than those which 
show no improvement. The longer the improved hearing continues 
after each inflation the more hopeful is the prognosis. The object of 
middle-ear inflation is to restore the normal air pressure to the cavity of 
the middle ear and to stretch or break down recent adhesions. It is quite 
probable that but little effect of this kind is produced by this procedure, 
except in the early stages while the adhesive bands are slight and fragile. 
The chief use, therefore, of intratympanic inflation is to equalize the air 
pressure, and thus overcome in some measure the pressure upon the 
labyrinthine fluid and auditory nerve endings. 

Local medical treatment has but little if any curative effect. The medi- 
cated vapors and nebulae, so much extolled in the medical literature a few 
years ago, have no appreciable effect whatever, except such as may be 
explained by the inflation which usually accompanies their use. We may 
say the same in regard to many of the medicines injected through the 
Eustachian tubes, as their use is usually preceded by inflation. 

Numerous injections have been recommended for adhesive processes in 



730 THE EAR 

the middle ear, some of which seem to be followed by good results. Only 
those which have proved of special value will be referred to here. 

The following formula has been used extensively by Politzer through 
a catheter with favorable results : 

1$. — Sodii bicarb gr. x 

Glycerini . tt\ ix 

Aquae des q. s. gj — M. 

Ft. sol. 
Sig. — Inject 5 to 8 drops into the middle ear through a catheter 2 to 3 times per week. 

It acts mildly and does not cause irritation. 

Pilocarpine is another popular remedy, and should be used in a 2 per 
cent, solution, 5 to 6 drops being injected into the middle ear. Perspira- 
tion and salivation usually occur while the patient is still in the office, 
especially in those cases in which the membrane of the middle ear is still 
boggy and well supplied with bloodvessels. In the dry or trophic type 
these symptoms may not occur. It should not be used in patients with 
weak hearts. 

Delstanche recommended the injection of liquid vaseline into the 
middle ear through a catheter. M. A. Goldstein has also reported 
favorable results from its use. It is claimed that it lubricates and softens 
the fibrous tissue, and that the force used in its introduction stretches 
the fibrous bands and liberates the ossicles. Probably the only benefit 
is from the simultaneous inflation of the middle ear. 

Caution. — Whatever method of medication is used, extreme care 
should be exercised lest too great an irritation be produced by the remedy. 
Temporary improvement only follows excessive irritation. The case 
then rapidly passes into a worse condition than before treatment. 

Massage. — The alternate rarefaction and condensation of the air in the 
external acoustic (auditory) meatus moves the drum membrane back and 
forth. As the handle of the malleus is located between the layers of the 
drum membrane, it is also propelled inward and outward with the move- 
ments of the drumhead. If there are firm adhesions binding it to the 
promontory, it will not perform these excursions. 

Bing has recommended prolonged rarefaction of the air in the external 
auditory meatus by the use of an olive-tipped instrument inserted into the 
meatus. The tip is perforated and has a valve at its inner extremity. 
The air is withdrawn from the meatus through the rubber tubing, where- 
upon the air pressure closes the valve. In this way rarefaction can be 
maintained for one-half to one hour. He thinks that in some cases this 
is an advantage over simple alternating rarefaction and condensation of 
the air in the meatus. 

Lucae has devised a spring probe with a cup-shaped extremity to fit 
over the short process of the malleus. Pressure is exerted upon the 
short process, and then released, repeating the motion a number of 
times. This motion is transmitted to the other ossicles, the ankylosis 
and cicatricial adhesions being stretched or broken down. The treat- 
ments are very painful, and are, therefore, not used to any great extent. 
If this difficulty could be overcome, the use of the probe would prove 



ADHESIVE PROCESSES IN THE MIDDLE EAR 731 

of greater value. It might be advisable to administer nitrous oxide gas 
and use the probe during the brief anesthesia. There is little danger 
or inconvenience connected with this anesthetic, and the exigencies of 
the case often warrant its use. The injection of a 2 per cent, solution 
of cocaine into the middle ear through a catheter may also be practised 
to mitigate the pain. The use of Lucae's probe in suitable cases at 
intervals of seven to ten days, inflation being practised on alternate days, 
is sometimes helpful. If the element of pain can be eliminated, it is the 
remedy par excellence in cases in which the adhesive processes are not 
too far advanced. The hearing is sometimes improved to a remarkable 
degree, and the subjective noises correspondingly diminished. The im- 
provement is not permanent in a majority of cases, nor is there any 
method of treatment known which will make it so. 

The length of time during which any of the aforesaid treatments should 
be continued varies. It should only be continued w T hile the hearing dis- 
tance continues to increase. This usually ranges between two and six 
weeks. The greatest amount of improvement occurs during the first six 
or eight days. To continue the treatments longer than improvement of the 
hearing distance increases often leads to ill effects. 

As the improvement in hearing is temporary, it becomes necessary 
to give occasional treatments to maintain the beneficial effects realized. 
Politzer thinks his method of inflation the best adapted for the after- 
treatments. 

Stenosis of the Eustachian tube may be overcome by inflation if due to 
accumulated mucus, or by the use of soft rubber sounds (Yankauer) if 
due to fibrous bands or rings within its lumen. They should be intro- 
duced through the Eustachian catheter. In the adult the tube is about 
one and one-half inches long, and the sound should be passed through 
its entire length. Sounds may be made of whalebone, catgut, celluloid, 
or rubber. If for any reason it is desirable to locate the stricture, an 
olive-tipped bougie should be used, whereas to secure therapeutic effect 
a sound with a filiform tip should be used. Medicated bougies (silk- 
worm gut) may be used and left in place for twenty or thirty minutes. 
A solution of the nitrate of silver is the astringent chiefly used for this 
purpose. 

The introduction of the sound should be done with extreme caution 
and gentleness, as force may cause it to penetrate the mucosa of the 
tube. This would be unfortunate, as subsequent inflation might cause 
emphysema of the submucous tissues. This accident occasionally 
happens in catheterization of the tubes through abrasions made during 
the manipulation of the bougie. The dilatation with the rubber sounds 
should be made daily for a few weeks, larger and larger sounds being used 
every few days until the stricture is completely overcome. The intervals 
between treatments may then be prolonged, until finally they are weeks or 
months apart. 

Internal medication is of value in those cases suffering from consti- 
tutional diseases. I have seen cases resist all treatment until iron and 
arsenic were administered. Others will improve in hearing when the 



732 THE EAR 

iodide of potash or tonics are given. But even these cases do not entirely 
recover; they only become somewhat improved in hearing and tinnitus. 

I am indebted to Dr. Geo. F. Suker for the following analysis of the 
conditions of the ear in which thiosinamin is indicated. In 1897-98 
he used it in a number of such cases, and bases his conclusions upon 
this experience together with the literature concerning its use in other 
conditions: 

The class of cases in which thiosinamin has been found of value 
come under the following heads: 

1. So-called catarrhal deafness in which there is a diapedesis of 
leukocytes into the meshes of the membrana tympani which ultimately 
cause cicatricial-like thickening. 

2. Subacute suppurative otitis media with a small perforation of the 
drum. The latter is thickened by infiltrations, but there is no true 
fibrous ankylosis of the ossicles. 

3. Inflammation of the middle ear, suppurative or otherwise, leading 
to a fibrous ankylosis of the ossicles and with very slight structural 
changes of any kind in the membrana tympani. 

4. Deafness, rather a loss in the acuity of hearing, due, as we have 
reasons to suppose, to some fibrous changes in the auditory nerve or 
its endings. 

5. Cases in which two or more of the above-mentioned conditions are 
present in the ear. 

6. Suppurative otitis media with extensive loss of drum substance 
and the formation of fibrous bands which impede the free action of the 
ossicles. 

7. Cases in which there is a transudation of the lymph into the 
substance of the drum, which, instead of being absorbed, remains and 
becomes partly organized, thus causing drum thickening, and, therefore, 
interferes with the transmission of sound waves. 

All such cases, if the thiosinamin is persistently given in alternating 
periods of time, will be markedly benefited. It may be administered by 
the mouth or hypodermically. If by the mouth, the dose should be 
rapidly increased until 6 to 10 grains per day are taken. If employed 
hypodermically, use a 10 per cent, solution in equal parts of glycerin and 
water. Of this give 12 to 18 c.mm. three times a week. 

Thiosinamin acts as a glandular stimulant ; at first it causes a breaking 
down of the exudate. Its powers of removing or absorbing an exudate 
is not unlike that of potassium iodide and mercury, peptone, pepsin, 
sodium urate, and allied bodies. 

In employing the thiosinamin treatment, the hygienic and other 
needed regime must not be overlooked. Give it for periods of six to 
eight weeks, and then cease for a week or ten days, after which begin 
again. 

Whether or not larger experience will support the claims thus clearly 
set forth remains to be demonstrated. Enough evidence is available, 
however, to justify extended trials of it. Its favorable action on keloids 
and lupus is well known. 



ADHESIVE PROCESSES IN THE MIDDLE EAR 



733 



Fig. 414 



Rest is another therapeutic measure of special value in neurasthenic 
cases. I have seen cases make material improvement both in hearing 
and in the severity of the subjective noises under this mode of treatment. 
J. A. Stucky reports good results following rest in bed, with massage of 
the body. 

Surgical Treatment. — Operations on the drumhead for the relief of deaf- 
ness have been performed for more than a century. Himly and Astley 
Cooper, in 1795, removed portions of the drumhead and strongly recom- 
mended the procedure as a means 
of admitting sound waves to the 
labyrinth and of relieving the in- 
creased tension of the ossicular chain. 
Others soon followed in their wake, 
all to meet with ultimate disappoint- 
ment, as the relief was only tempo- 
rary. It was found impossible to 
keep the wound open for any length 
of time. Later, vulcanite and metal 
eyelets were used with unsatisfactory 
results. All efforts to maintain the 
opening in the membrana tympani 
(drumhead) have failed. The diffi- 
culty has been to secure the epider- 
mization of the edges of the wounded 
membrane. The author suggests the 
use of small skin grafts on the mar- 
gin of the perforation, after the 
Thiersch method. 

Malherbe recommends lifting the 
auricle forward and the removal of 
the posterior wall of the meatus 
external to the annulus tympanicus, 
as in the meatomastoid operation. 
He then establishes communication 
between the middle ear and the 
meatus via the antrum and the 
aditus ad antrum. The opening is 
maintained by inserting a celluloid or 

gold tube through the opening in the wall of the meatus. He only recom- 
mends this procedure in cases of moderate severity. An improvement 
over this method would be to form the Ballance plastic flaps and reflect 
them through the opening in the meatus, as described under the meato- 
mastoid operation. This would obviate the necessity of wearing the 
vulcanite tube recommended by Malherbe. 

Section of the posterior fold of the drumhead (Fig. 397) was first sug- 
gested by Politzer in 1871: "It is advisable in all cases where the 
objective signs of an abnormal inward curvature of the membrana 
tympani are present, where the inferior extremity of the handle of the 





Severing an adhesion of the membrana 
tympani to the promontory. A small tri- 
angular flap is made in the drumhead and 
the right-angle knife introduced through the 
opening thus made and the adhesive band 
severed. 



734 THE EAR 

malleus is, therefore, abnormally inward, and the short process of the 
malleus and the posterior fold of the membrane extending from it pro- 
ject strongly toward the external meatus. If these changes are com- 
bined with a disturbance of hearing of a high degree and loud subjective 
noises, which cannot be materially improved by the local methods of 
treatment, an experimental section of the posterior fold is justifiable in 
such cases." 

The operation is simple and consists of a section of the fold just 
posterior to the short process of the malleus or midway between it and 
the peripheral extremity of the fold. The knife should not penetrate 
deep enough to sever the chorda tympani nerve in its passage between 
the malleus and incus. 

The handle of the malleus should immediately drop downward and 
forward as the tension is relieved. The tinnitus is usually most relieved, 
although in some cases there is also an improvement in hearing. The 
benefit lasts only a few weeks or months in most cases. 

Adhesion of the drumhead to the promontory may be overcome by 
making a small triangular opening in the drumhead and introducing a 
right-angle knife through it. The adhesion is then severed, as shown 
in Fig. 414. 

Dr. Sidney Yankauer has, perhaps, devised the best means of treating 
obstinate old strictures at the isthmus via the external auditory canal. 
As the drumhead is rarely perforated in adhesive processes, it is necessary 
to incise it anterior to and on a level with the umbo of the malleus, this 
being in a position corresponding with the tympanic orifice of the 
Eustachian tube. Through this opening the probe is introduced and 
directed downward, inward, and forward to the isthmus of the tube. 
The presence of a dehiscence or caries of the bony wall may be detected. 
The first by the softness of the tissue and the latter by the rough grating of 
the probe over the surface of the bone. Having explored the tube, the 
salpingitome should be introduced in a similar manner until its end 
passes through the isthmus. The instrument should then be pressed 
backward and downward to force the blade through the stricture; it is 
then withdrawn, incising the mucous membrane to the bone. 

The above procedure should be preceded by the application of a 
5 per cent, solution of cocaine to the pharyngeal end of the tube through 
a catheter, and to the middle-ear cavity through the incision in the 
drumhead. 



CHAPTER XLII 

OTOSCLEROSIS; SPONGIFYING OF THE BONY CAPSULE 
OF THE LABYRINTH* 

Synonyms. — Otitis media insidiosa; hyperplasia of the bony capsule 
of the labyrinth; capsulitis labyrinthii. 

In a recent article read by Denker before the International Otological 
Congress at Boston the following definition was presented: 

We understand by otosclerosis a disease in which there is a permeable 
tube and a normal tympanic membrane, accompanied by a definite 
and characteristically marked clinical picture of a progressive difficulty 
in hearing, as shown by the functional tests. As a pathologic-anatomic 
foundation for the disease, investigations have revealed a loss of move- 
ment of the stapes brought on by bony ankylosis in its framework or 
in the niche of the oval window, and a progressive spongification of the 
bony capsule of the labyrinth. 

To this definition, upon the ground of our present knowledge, must 
be added that, in addition to the disease of the bone, there is to be 
found, as shown by a histologic examination of a large number of 
cases, an atrophic degenerative process in the nerve endings in the 
membranous labyrinth. 

Only the forms of disease which clinically and pathologic-anatom- 
ically correspond to the above definition will be dealt with, and not 
those forms of chronic affections accompanied by thickening of the 
interstitial connective tissue, which, because of changes on the tym- 
panic membrane are recognized as chronic adhesive processes, or as 
the residues of long-standing middle-ear suppurations. 

Etiology. — There are two schools of thought in reference to the causes 
of otosclerosis, 

1. The disease of the bony capsule is secondary to an inflammation of 
the membrane lining the tympanic cavity. Habermann examined 13 
cases and arrived at the conclusion that the disease of the bone is 
secondary to middle-ear inflammation which extends along the larger 
bloodvessels and is disseminated in the bone through the medullary 
spaces. Katz and Toynbee consider it rheumatic inflammation of 
the stapediovestibular articulation and call it "arthritis rheuniatica." 
Schilling and Scheibe also regard it as of inflammatory origin. 

2. The disease of the bony capsule originates in the bone. In 1867 
Moss first expressed the opinion that in view of the absence of any 
change in the mucous membrane of the middle ear, the disease must 
be an ostitic process in the temporal bone. Bezold and Scheibe, after 
examining a number of temporal bones affected by this disease, said 

1 1 am greatly indebted to an article by Henry J. Hertz, wherein he reviewed the work of 
Continental observers, for most of the data presented in this chapter. 

(735) 



736 THE EAR 

that the disease must originate either in the bony capsule of the laby- 
rinth or in the periosteum of the niche of the oval window. Alfred 
Denker quotes Politzer and J. M oiler as saying that the greatest changes 
were found in the deeper layers of the bone, most of the cases failing 
to show pathologic changes in the mucous membrane. Hanan, a 
pathologic-anatomist, who examined the specimens from the cases 
reported by Hartmann from the Siebermann clinic, contends that the 
process at the stapes and niche of the oval window is a hyperostosis 
with a rebuilding of the bone, and designates this new-formed bone as 
metaplastic connective-tissue bone, originating from the periosteum. 
Siebermann, however, arrived at the conclusion that the spongification 
does not arise in the periosteum, nor does it develop primarily from 
the labyrinth capsule, but that the oldest parts are to be found at the 
junction of the labyrinth capsule, which is formed out of the endo- 
chondrial substance, with the connective-tissue bone arising secondarily 
from the periosteum (probably in the last-named structure itself). 
Briihl also supports this opinion. Hegener is of the opinion that the 
bony change and the disease of the auditory nerve must be differentiated 
from each other, and that the acoustic affection is not a result of the 
bony changes. Manasse also agrees with Siebermann that the disease 
originates in the labyrinthine capsule. Denker is likewise strongly 
committed to this view, though he points out that there is in some 
cases an association of bony and mucous membrane disease, but that 
the disease of the mucous membrane might be secondary or accidental. 

Manasse, believing the bone changes to be inflammatory in character 
(originating in the bone and not in the mucous membrane of the middle 
ear), has designated the process "ostitis chronica metaplastica of the 
labyrinth capsule. " Briihl and Orth, according to Denker, believe that 
the disease is a "spongy hyperostosis," brought about by means of the 
vessels of the hyperplastic periosteum, and the vessels of the Haversian 
canals absorbing the old bone, which is followed by a regular, even, 
excessive formation of connective-tissue bone. 

Siebermann, after careful study of a large number of temporal bones, 
comes to another conclusion. According to him, the beginning of 
the progressive spongification of the labyrinth capsule occurs, not as 
Manasse supposes, in an extension through new bone, but in the inward 
growth of cells from the periosteal tissue through the bone covering 
into the normal Haversian canals of the labyrinth capsule. Lacunar 
resorption from the walls, with the aid of mono- and polynuclear osteo- 
blasts, goes hand-in-hand with it, and fails in no case. New bone appo- 
sition results only where resorption processes have taken place. The 
newly apposed bone contains more chalk than the old, and does not 
deserve to be known as the osteoid substance. As a differentiation 
from ostitis fibrosa, the spongifying process of the labyrinth capsule 
occurs, without inflammatory symptoms. Granulation tissue, leuko- 
cytes, and plasma cells are not present. 

That trauma lead to stapes ankylosis, with the functional symptoms 
of otosclerosis was shown by a case published by Politzer in 1862. If 
we review what has been written concerning the etiology of otosclerosis, 



OTOSCLEROSIS 737 

it seems correct to state that in the majority of cases, at least, we have 
to do with an hereditary analogue as the cause of the disease. This pre- 
disposition lays the foundation upon which, under the influence of 
certain stimuli, there arises the affection with the characteristic symp- 
toms and pathologic-anatomic changes. These stimuli are the increased 
bony formation during puberty, and the bony changes during preg- 
nancy and the puerperium, which are probably dependent on the 
hyperplasia of the hypophysis, which appears during pregnancy. Fur- 
thermore, Denker believes the circulatory disturbances such as are 
present in arteriosclerosis, vasomotor neurosis, and lues may give the 
impetus to the development of the disease. It has not yet been proved 
that the continuous movement of the stapedial foot plate and the per- 
manent contraction of the musculus tensor tympani can be regarded 
as a cause for the fact that the bony alterations which develop by 
predilection at the anterior circumference of the vestibular window, as 
Briihl claims. 

The dense bone of the osseous capsule of the labyrinth contains 
cartilaginous cells, hence it is the area of election for the transformation 
of the cartilage into bone. The ossicles also have cartilage cells in 
them, and may be the seat of this disease. The distribution of the 
cartilage cells is most constant in the posterior half of the margin of the 
oval window (fenestra of the vestibule). They are also found in the 
capsule of the semicircular canals and the upper and lower walls of the 
cochlea. Any or all of these points may be affected and give rise to 
symptoms peculiar to the physiological bearings of the various 
structures. That is, the hyperostosis may be limited to the ossicles, 
the oval window, the cochlea, or to the semicircular canals, or it may 
involve two or more of them at once. 

Age exerts a positive influence upon the development of the disease. 
It usually begins between the eighteenth and the fortieth years of life. 
Heredity has been noted as a rather common factor in the etiology, many 
cases giving a history of other members of the family having had the 
disease. In a noted American literary family several members were 
affected by it. The majority of the cases occur in young women. 
Sexual intercourse and parturition aggravate the symptoms, probably 
on account of the increased hyperemia produced by these acts, or it 
may be due to the hyperplasia of the hypophysis which occurs in 
pregnant women. The marriage of women affected by this disease 
should, therefore, be carefully considered before being consummated. 

Pathology. — According to Denker, the osseous changes may be divided 
into two stages, the first of which consists in an active proliferation of all 
the cellular elements within the bone. New vascular and cellular tissue 
is formed in the narrow spaces and in the Haversian canals. Among 
the new-formed bone cells may be found giant cells, under the influence 
of which the basement of the bone substance is principally absorbed. 
Hollow spaces are formed, and areas of erosion gradually undermine 
the original compact bone, which becomes traversed by irregular 
and abnormal channels. With the absorptive process there is the 
47 



738 THE EAR 

formation and apposition of new bone, which is unlike the original, in 
that it is more voluminous and porous. The second stage is ushered in 
when the progressive changes cease and when the new bone assumes a 
lamellar structure. Then the abnormally large and thick bone corpuscles 
are found concentrically arranged, and the nuclei undergo atrophy. The 
vascular system is likewise gradually altered by the formation of connec- 
tive tissue, in which at times may be found fat cells. The Haversian 
canals and spaces have been changed in structure by this resorptive and 
appositional process, and all the cartilaginous elements have been meta- 
morphosed into osseous tissue, as it cannot be found in the newgrowth. 
Thus the process constitutes not only hyperplasia and hyperostosis, 
but also a metaplasia. 

The new structure differs from the normal by its affinity and greater 
absorptive power for carmine stains, which fact is utilized in the differ- 
ential diagnosis. The microscopic evidence of this new formation is the 
osteophytes, situated usually near the stapes articulation. Frequently 
the stapes is partially absorbed by penetrating bloodvessels and replaced 
by osseous formations, and sometimes a dislocation of the stapes is pro- 
duced by an encroachment of the osteophytes. The functions of the oval 
and round windows may also be seriously interfered with by the hyperos- 
tosis producing partial or complete occlusion. When the process invades 
the base of the cochlea, the patency of the Eustachian tube is threatened, 
and the microscope shows its lumen to be narrowed by thickening of 
the periosteum. Owing to the great vascularity attending the process, 
especially in the first stage, it is probable that the distressing tinnitus of 
progressive deafness may have its origin in the increased capillary 
circulation. 

The structural alteration consequent upon an invasion of this bone 
into the cochlea and the semicircular canals may cause a change in the 
pressure of the labyrinthine fluid. The mechanical and physical qualities 
of the endolymph and perilymph may be so altered as to interfere with 
the nutrition of the parts and induce disease. The detonating sounds 
heard by some patients and Meniere's symptom complex may be 
ascribed to a perforation of the septum dividing the endolymph and 
perilymph. 

While the histological alterations are found to be identical by dif- 
ferent authorities, yet their designation of the bone hyperplasia differs 
and new terms are consequently introduced. Politzer defines it as cap- 
sulitis labyrinthii or otosclerosis. Siebenmann, noting the resemblance 
to sponge because of the rarefied spaces and porous structures, desig- 
nated the new formation as spongification. Katz compares the process 
to Volkmann's osteitis vascularis chronica. 

Symptoms and Diagnosis. — The symptoms, while more or less con- 
stant, vary with the anatomical structures involved. If only the ossicles 
are affected, the ankylosis of the stapes may be partial or complete; if the 
posterior bony margin of the oval window is the seat of the changes, 
the ankylosis may be complete and the stirrup pulled posteriorly by the 
stapedius muscle; if the cochlea is involved, the signs of nervous deafness 



OTOSCLEROSIS 739 

are present, i. e., diminished bone conduction and the loss of hearing for 
the upper tone limit; if the process is in the semicircular canals, giddiness 
and nausea may be present. In mixed cases there may be a combination 
of these symptoms. 

In the cases commonly recognized in practice, the disease is charac- 
terized by the signs of middle-ear disease without the objective appear- 
ances of it. That is, there is (a) loss of the lower tone limit, (b) a nega- 
tive Rhine, and (c) an increased duration of hearing by bone conduction, 
all symptoms found in middle-ear disease, but upon inspection of the 
membrana tympani its appearance is normal, or is so slightly changed 
that it cannot account for the marked degree of deafness present, and the 
Eustachian tube is normally patent. 

When the hyperostosis is located exclusively in the ossicles, and the 
ankylosis is partial or complete, the symptoms are those of ordinary 
middle-ear disease, except the membrana tympani is normal in appear- 
ance and the Eustachian tube open. 

When the hyperostosis is limited to the cochlea, the usual signs of ner- 
vous deafness, loss of hearing for the upper tone limit, positive Rinne, and 
shortened and diminished bone conduction are present. 

When both the oval window and the cochlea are involved, it is prac- 
tically impossible to make a diagnosis. This is also true when the oval 
window is affected by hyperostosis (spongification) and the middle ear 
is simultaneously diseased. Tinnitus is present in nearly all cases, 
and is sometimes very pronounced. The paracusis Willisii is more 
pronounced than in any other form of ear disease. 

Summary of Symptoms. — As the spongifying or hyperostosis 
affects various parts of the ear structures, the symptoms vary accord- 

The following classification includes the chief clinical characteristics 
of each subdivision: 

Hyperostosis about the Oval Window (Fenestra of Vestibule). — 1. Loss 
of hearing for one-half to one and a half octaves of the lower tone limit 
in one or both ears. 

2. Negative Rinne in varying degree. 

3. Prolongation of hearing by bone conduction for fork A of the 
Edlemann-Bezold set of forks (Schwaback test). 

4. Hyperemia of the promontory, appearing as a yellowish-red glow 
through a membrana tympani otherwise normal in appearance. The 
handle of the malleus may be foreshortened, but is not rotated. 

5. Patency of the Eustachian tubes. 

Hyperostosis of the Stapes. — The same as the preceding except in a 
less degree. 

Hyperostosis of the Cochlea. — 1. Loss of hearing for the upper tone 
limit, and slightly for the lower tone limit. Shambaugh reported a case 
in which there were islands of deafness, thereby showing that the hyper- 
ostosis may be limited to definite isolated areas in the cochlea. 

2. Positive Rinne. 

3. Shortened duration of hearing by bone conduction for fork A, on 
account of the degeneration of the membranous cochleae. 



740 THE EAR 

4. Hyperemia of promontory showing through an otherwise normal 
membrana tympani. 

5. Patency of Eustachian tubes may be affected by the thickening 
of the periosteum. 

6. Loud, subjective noises are often complained of. 

Hyperostosis of the Semicircular Canals. — 1. Giddiness or dizziness 
at times. 

2. Xausea may or may not be present. 

3. Perhaps slight deafness. 

4. Membrana tympani and Eustachian tubes normal. 

5. Subjective noises, often of a loud, popping character. 
Hyperostosis Around Oval Window Combined with Catarrhal Otitis Media 

or Other Middle-ear Diseases. — 1. Loss of hearing for one-half to two 
octaves of the lower tone limit. 

2. Negative Rinne in varying degree. 

3. Prolonged bearing by bone conduction for fork A. 

4. Retraction of the membrana tympani. 

5. Foreshortening and rotation of the malleus. 

6. Eustachian tubes obstructed. 

7. Subjective noises are usually present. 

A positive diagnosis of spongifying in a case with the above symptom 
complex is impossible except at the postmortem examination, as it is 
masked by the catarrhal otitis media which presents the same symptom 
complex. 

Prognosis. — The cure of the disease appears to be impossible. In a 
few cases slight or temporary improvement follows treatment, and in the 
early stage of the disease certain medicinal, mechanical, and surgical 
procedures afford relief. In the later stages all remedial measures fail, 
unless, indeed, Lake's exposure of the horizontal canal and vestibule 
is resorted to on account of the distressing tinnitus and vertigo. (See 
Intractable and Unbearable Vertigo, p. 975.) 

Treatment. — Medicinal. — Small doses of phosphorus, gr. ^ three 
times daily, for six months of the year, have given the best results. The 
treatment acts best in the early stages during the active proliferation of 
the cellular elements within the bone, when new vascular tissue is being 
formed in the narrow spaces and Haversian canals, and the absorptive 
processes and apposition of new bone is in progress. 

Thyroid extract has likewise occasionally given good results under the 
same conditions. 

Iodine, in the form of the iodide of potash, and mercury have been 
given by Politzer with good results when the diagnosis was made early 
on account of other members of the family having had the disease. That 
is, its appearance was carefully watched for, because of the known 
hereditary influence present. When a father or mother is known to have 
the disease, they should be warned that their children are liable to the 
same trouble, and that they should be periodically examined after puberty 
for its earliest expression. In this way there is some hope of modifying 
its progress by the administration of phosphorus, iodide of potash, or 



OTOSCLEROSIS 741 

thyroid extract, and by the correction of inflammatory diseases of the 
tonsils and adenoids, and of rheumatic, gouty, and scrofulous diseases. 
Thyroidectin in five-grain doses may be given three times a day. Deple- 
tion of the vessels of the head may be produced by the administration 
of cathartics and by hot foot and sitz baths. 

To accomplish anything of importance an early diagnosis is positively 
necessary, and heredity should give warning of the impending disorder. 

Mechanical. — Pneumomassage with the Delstanche rarefactor (Fig. 
14) may be used to mobilize the ossicles when they are not excessively 
ankylosed (Hartz). 

Clarence Blake calls attention to the fact that in practising pneumo- 
massage, gentleness should be observed in its application, as otherwise 
the whole ossicular chain may be dislocated and irreparable damage 
done. He also calls attention to the fact that the posterior segment 
of the membrana tympani may become relaxed by excessive massage. 
Indeed, great damage may be done by any treatment addressed to the 
Eustachian tubes and middle ear. Aurophones are also damaging in 
this disease. The massage should, therefore, be gently administered, 
preferably with a hand pump, for one to two minutes, two or three times 
a week, for two months. After a rest of two months the massage may be 
tried again, provided improvement followed the first course of treatment. 
Further massage may be given at the discretion of the aurist. As soon 
as the nature of the disease is known, the patient should be advised to 
begin a systematic course in lip reading. 

Surgical. — Stapedectomy has been tried with almost universal failure. 
Jack has performed the operation a number of times with but one or two 
permanent improvements. In some cases, stapedectomy is followed by 
the formation of scar tissue over the oval window, thus rendering the 
hearing worse than before the operation. 

Prophylactic. — "An ounce of prevention is better than a pound of 
cure," is eminently exemplified in this disease. The prevention of 
conception, the avoidance of consanguineous marriages, catching cold, 
cold douches on the head, sea voyages, etc., will greatly diminish 
the number of cases, and modify the intensity of expression of those 
already developed. 



CHAPTEE XLIII 

ACUTE AND CHRONIC SUPPURATIVE OTITIS MEDIA 
CHOLESTEATOMA 

ACUTE SUPPURATIVE OTITIS MEDIA 

This type of inflammation of the middle ear is characterized by 
marked hyperemia of the mucous membrane of the middle ear, includ- 
ing the inner wall of the drumhead. This may be followed by pain and 
perforation of the drumhead, through which the pus discharges into 
the external auditory meatus. 

Etiology. — The exciting cause of this disease is the presence of patho- 
genic microorganisms in the middle ear, as already described under 
Acute Catarrhal Otitis Media; indeed, the catarrhal inflammation often 
assumes the suppurative type after a few days. In many cases the 
inflammation remains catarrhal in type until the drumhead is per- 
forated, the microorganisms thus receiving the required environment to 
promote their rapid propagation, though spontaneous rupture some- 
times promotes a rapid reparative process, due to good drainage and 
the increased reaction of inflammation. (See Chapter VI.) The per- 
foration may occur either spontaneously or by surgical intervention. 
Incision of the membrana tympani is not contraindicated, as, if it is done 
under aseptic conditions, the danger of increased infection is reduced to 
the minimum; indeed, the reaction of inflammation is promoted, and 
the infection is thus overcome instead of being increased. Some cases 
are undoubtedly suppurative in type from the beginning, the inflamma- 
tion, temperature, and pain being more pronounced than in the simple 
catarrhal inflammation. 

Arthur B. Duel arrives at the following conclusions in reference to the 
relation of the infectious fevers to acute suppurative otitis media, his 
conclusions being based upon a study of 6000 cases of scarlet fever, 
measles, and diphtheria in the Willard Parker Hospital : 

Acute purulent otitis developed in about 20 per cent, of the scarlet 
fever cases, in about 10 per cent, of the diphtheria cases, and in about 
5 per cent, of the cases of measles. There were 26 mastoid cases, 2 in 
measles, 2 in scarlet fever, and about 20 in combined scarlet fever and 
diphtheria. Two were complicated with thrombosis of the lateral 
sinus. 

Time of appearance : In scarlet fever the ear complications occurred 
the second or third week; in diphtheria, during the acute symptoms; in 
measles, during the acute stage, fever still being present/ 

In scarlet fever cases there was usually much greater destruction of 
(742) 



ACUTE SUPPURATIVE OTITIS MEDIA 743 

tissue than in those due to diphtheria or measles. A combination of two 
or more of the infectious diseases increased the danger, nearly one-half 
of such cases developing acute suppurative otitis media, and mastoiditis 
was a frequent sequela. 

The Rivinian segment as an etiological factor: In children under 
five years of age, Duel found postauricular swelling present most fre- 
quently, which, he thinks, was due to the escape of pus through the 
unclosed Rivinian segment. Between the ages of five and ten the post- 
auricular swelling was due to perforation of the thin mastoid cortex. 
In older children mastoid swelling was rare, except in those cases in 
which the external meatus was greatly inflamed. In all cases there was 
sagging of the postsuperior wall of the meatus near the drumhead. 

The predisposing causes are colds, exposure, chronic rhinitis, chronic 
and acute epipharyngitis, adenoids, enlarged or inflamed tonsils, syph- 
ilis, tuberculosis, and other constitutional diseases. The acute exan- 
thematous fevers, as scarlet fever, measles, diphtheria, whooping-cough, 
and influenza, are also responsible for many cases. The use of the 
nasal douche sometimes causes the disease. The author formerly used 
the nasal douche quite frequently in office practice, but abandoned it 
after seeing two or three cases of acute suppurative inflammation result- 
ing directly from it. Cold injections into the meatus, bathing, diving, 
and snuffing cold fluids into the nose also act as causes. 

Age has a direct influence, a large majority of the cases being in 
children. The damp, unsettled weather of autumn and spring also 
favors its occurrence. 

Those cases occurring independently of any other disease are usually 
unilateral, while those occurring in connection with scarlet fever, diph- 
theria, measles, epipharyngitis, and adenoids are usually bilateral. 

Finally, it may be stated that all conditions which lower the resistance 
of the tissues of the middle ear predispose to infectious inflammation. 
The exciting causes are the pathogenic microorganisms. The various 
constitutional diseases and the local diseases of the fauces, nose, and 
epipharynx produce lowered cell resistance, and predispose to the in- 
fection. 

The indications, in view of the foregoing facts, are to remove the pre- 
disposing causes and increase the reaction of inflammation, in order to 
increase the resistance of the tissues to the bacteria and their toxins. 
(See Inflammation, and the Methods of Promoting the Reaction of 
Inflammation, Chapters VI and VII.) 

Symptoms. — The symptoms may be grouped under pain, tempera- 
ture, the appearance of the membrana tympani, the character of the 
secretions, the subjective noises, and the disturbances of hearing. 

Pain. — The pain is sometimes preceded by a feeling of heaviness in 
the ear, or by a severe headache. It may be piercing, tearing, boring, 
or throbbing in character, and is more severe in children than in adults. 
It is continuous, but becomes less severe toward morning, when the 
patient falls into a sound sleep. Photophobia, edema of the eyelids, 
and conjunctivitis occasionally complicate severe inflammation prior 



744 THE EAR 

to the time of perforation of the drumhead. Facial paralysis and tri- 
geminal neuralgia occasionally complicate the disease. 

Temperature. — The temperature at the onset is elevated from 1° to 3° F., 
and is sometimes preceded by a slight chill, or creepy sensations, and, 
occasionally, in very young children, by convulsions. After the sup- 
purative process is well established, and drainage is taking place through 
the perforation in the drumhead, the temperature subsides to about 
1° above normal. 

Membrana Tympani. — In the early stages, the membrana tympani 
presents the appearances found in acute catarrhal otitis media. It is 
scarlet red, ecchymotic, swollen, and more or less bulging. The handle 
of the malleus is obscured by the swollen drumhead. In the post- 
superior quadrant of the membrana tympani a blister is sometimes pres- 
ent, giving a pearly lustre to this area. If the case is seen quite early, 
the round spots due to the bubbles of air in the viscid mucus may be 
seen through the still transparent drumhead. In the influenzal cases a 
hemorrhagic bleb often completely covers the drumhead. After a day 
or two the posterior half of the drumhead becomes covered with dead, 
cracked epithelium, beneath which there is a serous infiltration. Politzer 
was the first to show that the light reflexes on the bulging portions of the 
posterior segment of the drumhead sometimes pulsate. The yellow 
purulent secretion behind the membrana tympani does not show as often 
as one might expect, on account of the swollen and reddened condition 
of the drumhead. Occasionally, however, a greenish-yellow bulging spot 
may be seen, and when it appears, perforation is imminent. 

In diabetic patients, and occasionally in others, small interlamellar 
abscesses form in the posterior segment of the membrana tympani, or 
near the umbo. They are of the size of a millet-seed, and rupture early 
in the course of the disease. 

External Auditory Meatus. — The osseous portion of the meatus is 
almost always hyperemic, and is sometimes infiltrated, and more or less 
covered with blisters. The cartilaginous portion of the meatus is in- 
jected and painful in severe inflammations, the infection taking place 
through the numerous anastomoses of the capillary bloodvessels be- 
tween the mucous membrane of the tympanic cavity and the skin of the 
meatus. The swelling and redness, or the so-called "sagging" of the 
postsuperior portion of the osseous meatus, near the membrana tym- 
pani (Fig. 415), occurs in those cases in which there is a marked suppura- 
tive process in the border mastoid cells (the cells along the posterior 
border of the meatus). When it occurs it is usually a positive indication 
for the mastoid operation. 

Perforation. — Perforation takes place at the seat of one of the inter- 
lamellar abscesses, or at the most bulging portion of the drumhead, 
generally in the anterior half, although it may occur in the posterior 
segment. The size and shape of the perforation varies, usually being 
an ill-defined area with irregular edges, while in others it appears as a 
small dark round spot, with a pulsating drop of mucus covering it. In 
still other cases the opening cannot be located. Inflation sometimes 



ACUTE SUPPURATIVE OTITIS MEDIA 745 

enables the observer to distinguish its edges. The same is true when 
the air is rarefied in the external canal with Siegle's otoscope (Fig. 410). 
The perforation is usually single, except in tuberculous patients, when it 
is multiple and near the margin of the drumhead (Fig. 417). In influ- 
enzal otitis, the perforation often occurs on the apex of a nipple-shaped 
elevation. Such a perforation is, therefore, significant of serious mastoid 
disease. Even under favorable conditions, the nipple-shaped perfora- 
tion persists for some time. In those cases occurring independent of 
one of the infectious diseases, the perforation rarely exceeds the size of 
a millet-seed, whereas in cases secondary to the infectious fevers it may 
be so large as to destroy the entire membrana tympani. The membrana 
flaccida (ShrapnelFs membrane) is rarely perforated in acute suppurative 
otitis media. 

Secretions. — The secretions may be serous, seromucous, serosan- 
guineous, seropurulent, mucopurulent, or mucohemorrhagic. If it is 
purulent, it often runs a more favorable course than the mucopurulent 
type. The quantity of pus, serum, 

and mucus varies greatly at differ- FlG - 415 

ent times, and one form of secretion 
may alternate with another. In neph- 
ritic, cachectic, leukemic, hemophilic, 
and traumatic cases, the hemorrhagic 
secretion is usually present. 

Subjective Noises. — Pulsating noises 
sometimes occur in acute suppura- 
tive otitis media, although they are 
not always present. They are due 
to the increased pressure within the 
cavum tympani from the hyperemia 
and excess of secretion. The laby- 
rinth is also hyperemic and some- 
what infiltrated, the noises being Bulging ° r * agging + of the . poste + r . ior 

. P superior wall of the meatus; an imperative 

thereby augmented. AutopllOny is indication for the mastoid operation. 

sometimes present. 

Hearing. — The hearing is impaired somewhat in proportion to the 
amount of congestion and secretion present. As the disease progresses, 
and the membrane becomes more congested, and the cavity filled with 
the secretion, the deafness, which at first was slight, becomes quite pro- 
nounced. In scarlatinal and diphtheritic infections involving the laby- 
rinth, the deafness may be profound. 

Hearing by bone conduction for the watch, tuning-fork, and acou- 
meter remains intact, except in those cases wherein the labyrinth is 
involved. In the Weber test the sound is lateralized to the diseased ear, 
except in the aforesaid labyrinth cases, in which it is lateralized to the 
sound ear. 

Course. — Taking the perforation of the drumhead as one of the 
early milestones in the progress of the disease, we may subdivide it 
into three classes, namely: (a) Those cases running a very rapid and 




746 THE EAR 

destructive course, wherein the drumhead is perforated within the first 
one or two days; (b) those cases wherein perforation occurs on the 
third or fourth day (primary suppurative otitis media); (c) and the 
more chronic type, in which perforation occurs within the second or 
third week of the disease. 

Perforation usually ameliorates the symptoms, especially the pain 
and temperature. Improvement does not always follow, however, as 
the mastoid antrum and cells may also contain pent-up secretions, 
and thus give rise to pain and elevation of temperature, in spite of the 
lowered tension within the tympanic cavity. The fever, headache, and 
subjective noises are also abated when perforation and drainage into the 
meatus take place. 

After a variable time, the discharge ceases and the perforation closes. 
In the cases occurring independently of the infectious fevers, this will 
usually take place in from one to three weeks; sometimes, however, it may 
take as many months. In those cases due to the infectious fevers and to 
influenza (nipple-shaped perforation), the perforation only closes after a 
protracted period. 

I have seen a fatal type of mastoiditis develop seven years after an 
attack of mild scarlet fever. In one case, seven years after the scar- 
latinal infection, cavernous sinus thrombosis complicating mastoiditis 
occurred, and was speedily followed by death. In another case, one 
year after a very mild attack of measles, suppurative labyrinthitis de- 
veloped very suddenly, deafness being almost complete. Pachymenin- 
gitis, followed by death four days later, terminated the case. There is 
great danger for the safety of those patients whose ears become infected 
during the course of the exanthematous fevers. A latent or concealed 
inflammation so often persists, which after a lapse of a few years becomes 
very active and destructive. It is, therefore, always best to give a guarded 
prognosis in otitis media secondary to the eruptive fevers. The prognosis 
in those cases occurring independently of the exanthematous fevers is 
much more favorable. 

Another type of otitis having dangerous tendencies, is that running an 
irregular or intermittent course. The discharge ceases, and then, after 
a variable interval, reappears. Pain also occurs at irregular intervals. 
In other words, the acute type becomes chronic and somewhat latent 
in character. Necrosis of the bony tissue takes place, and mastoiditis, 
complicated with sinus thrombosis, brain abscess, or meningitis, occurs. 

Terminations and Sequelae. — This phase of the subject is of great 
importance, on account of the apparent harmlessness of the disease in 
many cases, whereas it is in reality a most grave and destructive one. 
It is not so much the disease that is to be feared as its sequelae. The 
terminations and sequelae should engage the thoughtful consideration 
of the attending physician quite as much as the primary otitis. For 
convenience of discussion, Politzer's classification of the terminations 
will be followed: 

(a) Cure. — That many cases terminate in a positive cure, no vestige 
of the disease remaining, cannot be questioned. That many are pro- 



ACUTE SUPPURATIVE OTITIS MEDIA 747 

nounced "cured" when in reality a serious sequela is left as a heritage, 
is also unquestioned. A careful analysis of the case, its etiology, course, 
etc., should be considered in arriving at a correct conclusion as to whether 
or not it is "cured." What, then, are the points that should be consid- 
ered in arriving at such a conclusion? In the first place, if the case is 
primary, or independent of a preceding infectious fever, and has run 
a mild and rapid course, and if there are no demonstrable ear lesions, 
it is safe to pronounce the case as probably cured. Such an opinion 
should, however, be based upon accurate and intelligent observations. 
I have seen many cases pronounced cured in which subsequent results 
demonstrated the opinion to have been erroneous. 

(b) Catarrhal. — A catarrhal termination is not attended with immediate 
serious consequences, but it may in time produce pronounced impair- 
ment of hearing. The perforation may become completely closed 
by cicatricial tissue and a seromucous secretion, with slowly increasing 
deafness and tinnitus as the chief symptoms. 

(c) Adhesive Processes. — This form of termination is comparatively 
common. The thick mucoid secretion or exudate becomes organized, 
the adhesive bands binding the ossicles to each other or to the wall 
of the tympanic cavity. The drumhead may also be involved by ad- 
hesions to the inner tympanic wall, forming ridges and folds toward 
the wall from which the adhesive bands spring. The deafness and 
tinnitus are usually progressive, although they may increase by bounds. 
In the earlier stages, bone conduction is increased, Rhine (see Func- 
tional Tests of Hearing) being negative, while in the more advanced 
stages Rinne is positive. The positive Rinne in the later stage is ac- 
counted for by the extension of the sclerotic process to the labyrinth. 

(d) Permanent Deafness. — Permanent deafness is usually a result of 
the secondary infection from scarlet fever, measles, diphtheria, etc., the 
membrana tympani and ossicles being partially or entirely destroyed. 
I have seen cases, however, in which the drumhead and ossicles were 
entirely destroyed and the inner wall (promontory) of the tympanic 
cavity plainly visible, in which the hearing was remarkably acute. The 
chief loss of function seemed to be an inability to locate the direction 
of sound or speech. After once grasping the fact that they were being 
addressed, these cases seemingly hear with almost normal acuteness. 
Another cause of permanent, and often very pronounced, deafness is the 
panotitis of Politzer, wherein the whole auditory apparatus is involved 
in the infective process. In these cases there is caries of the bone sepa- 
rating the tympanic cavity from the labyrinth (promontory), or there is 
a perforation of the round window leading to the labyrinth. This con- 
dition is usually secondary to the infectious fevers. 

(e) Mastoiditis. — While mastoiditis nearly always complicates middle- 
ear infection, it is not always severe enough to cause serious symptoms. 
In some cases, however, notably those due to the infectious fevers, in- 
fluenza, and typhoid fever, the mastoid involvement often becomes the 
chief problem in the management of the case. In mastoiditis having its 
origin in influenza, the abscess is usually circumscribed, and is located 



748 THE EAR 

in the mastoid process, the tympanic cavity containing no pus. In 
children, the mastoid process is often perforated through the external 
plate, thus giving rise to a subperiosteal abscess. 

(/) Loss of Mucous Membrane, Ossicles, and Infection of the Labyrinth. 
— Labyrinthitis, described under (d) Permanent Deafness, is found 
following mild infectious fevers, typhoid fever, and tuberculosis. The 
tympanic cavity is denuded of mucous membrane, and the ossicles are 
necrosed. A probe introduced into the cavity through the external 
meatus shows bare, comparatively smooth bony walls. The labyrinth 
may be exposed by necrosis of the promontory or inner wall of the 
middle ear, or the wall of the horizontal semicircular canal may be 
perforated. The hearing in these cases may not be as profoundly affected 
as in (d), except when the cochlea is involved. 

(g) Chronic Suppuration. — This sequela is not so much to be dreaded 
as the more latent form, in which there seems to be a cure, when in fact 
necrosis may be steadily progressing. In the plainly manifested chronic 
suppuration the physician and patient are not so readily deceived, but 
recognize the possible danger still attending the further progress of the 
disease. 

(h) Death. — A fatal issue may result early in the disease from menin- 
gitis, sinus thrombosis, septicemia, or brain abscess. The infection 
may reach the meninges through the labyrinth, the tegmen antri or 
tympani, or through one of the open sutures of the temporal bone in 
infants and young children. 

Diagnosis. — The diagnosis of acute suppurative otitis media in the 
early stage is neither easy nor simple. The apparent difference between 
it and acute catarrhal otitis media is often so slight that only a careful 
and intelligent examination will enable the surgeon to make a correct 
diagnosis. 

(a) Pain. — In suppurative otitis media the pain previous to per- 
foration is very intense and boring in character, especially in chil- 
dren. 

(b) Temperature. — The temperature ranges from 1° to 3°, or even 
more, above normal in children, but may not run so high in adults. 
In catarrhal otitis media the temperature does not usually exceed 1° or 2° 
above normal. 

(c) Appearance of the Drumhead. — In suppurative otitis media before 
perforation, the drumhead is quite similar in appearance to that in 
catarrhal otitis media. The perforation may appear as a dark spot or 
it may not be visible. A pulsating droplet of mucus or pus is, however, 
significant of perforation. If the drumhead is destroyed, the red pro- 
montory may be seen when the pus is cleared away. 

(d) The Probe. — The probe may be used to differentiate between a 
reddened promontory wall and a reddened drumhead. The promon- 
tory is firm and unyielding, while the drumhead is resilient. With the 
probe, a flake of mucus or pus may be brushed away, and thus show 
whether a perforation is present. Necrosis of the promontory or cochlear 
wall may also be demonstrated with the probe. In the acute stage 



ACUTE SUPPURATIVE OTITIS MEDIA 749 

nystagmus, nausea, and vomiting may be present when the labyrinth is 
involved. (See Tests of Vestibular Apparatus.) 

(e) Inflation. — Inflation of the middle ear and the simultaneous use 
of the diagnostic tube will produce a whistling tympanic murmur when 
perforation is present, and a soft, blowing tympanic murmur when the 
drumhead is intact. Inflation should be practised with caution in acute 
cases, as the infectious material may be forced into the deeper recesses 
of the tympanic and mastoid cavities. If during inflation, the distal 
end of the diagnostic tube is dropped into a basin of water, bubbles 
of air will arise in the water if perforation is present. A manometric 
tube partly filled with water and inserted into the external meatus 
during inflation will cause the column of water to rise in the distal arm 
of the U-shaped tube during inflation if a perforation is present. 

(j) Compression of Air in the Meatus. — Compression of the air in the 
external canal will force air through the perforation into the middle ear. 
The sound may be heard by inserting one end of the diagnostic tube into 
the nose of the patient (one nostril being closed), the other end being 
placed in the external auditory meatus of the observer. 

Prognosis. — The prognosis has already been quite fully considered 
under Terminations and Sequelae. 

Treatment. — The treatment will be considered in connection with 
the subject of middle- ear suppurations in general. A brief resume, 
however, will be given in this connection. 

(a) Complete asepsis or cleanliness and drainage should be striven 
for, to prevent the otorrhea becoming chronic. To fail in this regard 
subjects the patient's life to great hazard. If thorough asepsis is main- 
tained, a secondary staphylococcus infection will be prevented. Staphylo- 
coccus infection means chronicity. Do not allow it to occur. 

(b) In the early stage, before perforation occurs, a 12 per cent, solu- 
tion of carbolic acid in glycerin should be dropped into the meatus. 
It is also a valuable remedy after perforation, as it is hygroscopic, reduces 
the edema of the mucous membrane, and thus establishes a more rapid 
flow of blood through the tissues. The resistance of the tissues is thus 
raised and the infection checked. 

(c) Early incision of the drumhead should be practised at its most 
bulging portion. The incision should be free and curved to allow of 
good drainage. Simple puncture, the so-called paracentesis, is never 
indicated. It is an obsolete procedure. Drainage is the object sought 
for, hence use the lance with a free hand. Incision also promotes the 
reaction of inflammation, and thus favors a speedy resolution (Fig. 416). 

(d) If the secretion is thick and tenacious, the syringe may be used to 
remove it. A sterile alkaline solution should always be used for this 
purpose, as it thins the secretion and facilitates its removal. 

(e) An aqueous solution of the peroxide of hydrogen may also be 
used to break down the secretion, after which it may be more readily 
wiped away with a cotton-wound probe. 

(/) The cotton- wound probe should be used gently, but repeatedly, at 
each sitting. In the author's experience, this is the most effectual method 




750 THE EAR 

of removing the secretion in those cases in which the perforation is of 
large size. 

(g) Inflation of the middle ear may be practised with caution after 
the pain and other acute symptoms have subsided. 

(h) A safer procedure is to use suction with Siegle's otoscope in the 
external auditory canal. 

(i) Constitutional treatment: Calomel may be given in -^ grain doses 
three to ten times a day. For the relief of the pain, 1 grain of codeine, 

or 3 to 6 grains of phenacetin, may be 
Fig. 416 given. The epipharynx should be fre- 
quently gargled after the von Troltsch- 
Swain method, the patient lying upon his 
back. 

(y) Six weeks of daily inspection and 
appropriate treatment will, in most cases, 
result in a complete cure. Less faithful 
and intelligent attention will result in 
many cases becoming latent or chronic, 
with the usual sequelae so unfortunate in 
their effects. 

A long curved incision extending ^x j n ^ caseg ^ which there J g 

across the drumhead and into the • j» l 

meatus at the upper portion. sagging of the postsupenor meatal wall the 

simple mastoid operation should be per- 
formed at once. Delay is dangerous. If the infection is staphylococcal, 
the urgency for the operation is not so great as in streptococcus infec- 
tion. In the latter type, local treatment is usually unavailing, surgical 
procedures being required to effect a cure. 

(/) The ice-bag may be used over the mastoid process for one-half to 
two hours when great pain is present. If no improvement follows, it 
should be discontinued and operative measures considered. Discon- 
tinue the ice when pus flows freely and the pain subsides. If the infec- 
tion is streptococcal, its use will be unavailing. If it is staphylococcal, 
it may abate the infective process. 

(m) Artificial or natural leeches, applied over the mastoid process and 
in front of the tragus, afford the most effectual method of promoting the 
reaction of inflammation and aborting the disease. (See Chapter VII.) 



ACUTE SUPPURATIVE OTITIS MEDIA IN INFANTS AND 
CHILDREN 

In view of the fact that in 50 per cent, of the cases of measles in infants 
and young children there is an inflammatory affection of the middle ear, 
and that with all infectious diseases in young patients there is more or 
less inflammation of the ears, a brief consideration of these inflammations 
is in order. 

The pathological changes found vary all the way from a simple catar- 
rhal inflammation, with swelling and cloudiness of the mucosa, to infil- 



ACUTE SUPPURATIVE OTITIS MEDIA IN CHILDREN 751 

tration and purulent secretion. This secretion is usually serous or sero- 
mucous, with some pus cells. 

The enibryological conditions influencing the occurrences of the process 
in infants are : (a) The presence of an opening in the upper or Rivinian 
segment of the drumhead, which does not always close before birth. In 
bathing, water may thus gain entrance into the tympanic cavity and 
excite an inflammation, (b) According to Weiss, the mucous membrane 
of infants is embryonic in type, and is, therefore, more liable to become 
infected. 

The cachexia of infancy, bronchitis, the infectious fevers, and chronic 
intestinal catarrh are also special causes. 

Coughing, vomiting, sneezing, and other violent respiratory efforts 
may force infected matter through the Eustachian tubes into the middle 
ears and excite catarrhal and suppurative inflammations. 

Otitis media is sometimes present in the newborn, and is probably due 
to the forcible entrance of amniotic fluid into the middle ear during 
delivery. 

Adenoids, enlarged or diseased tonsils, epipharyngitis, and coryza are 
common diseases of childhood, and contribute toward the causation of 
otitis media. 

Symptoms. — In infants with cachexia there are often no subjective 
symptoms. Objectively, the drumhead may be a little reddened, espe- 
cially about the short process and along the handle of the malleus. A 
small amount of slimy secretion may be found in the canal. It may 
be questioned whether the cachexia is the cause of the ear disease, 
or the ear disease is the cause of the cachexia. It is quite certain, 
however, that even a mild suppurative process in infants is quite suffi- 
cient to cause pronounced disturbances of nutrition. Every case of 
malnutrition, peevishness, twisting of the head, or dropping it to one 
side should lead to the careful inspection of the ears of these young 
patients. Boring the head, or occiput, into the pillow, hanging it to one 
side (affected ear), placing the hand to the affected ear, going to sleep 
when lying on the ear toward which the head is inclined, refusing to 
take the breast except on the side which allows the patient to lie with 
the affected ear against the bosom, all point to acute inflammation of 
the middle ear. The infant cannot tell of its sufferings, but if the 
physician carefully observes its actions, they will often speak louder 
than words. 

In older children, the symptoms are more pronounced, and just prior 
to perforation of the drumhead the pain is often excruciating. There 
may be nystagmus, vomiting, unconsciousness, and convulsions. In other 
words, signs of labyrinthine and meningeal irritation are often present. 

When perforation takes place, there is immediate relief, although the 
patient is by no means necessarily out of danger, especially if labyrin- 
thine and meningeal symptoms are present. 

The tendency to frequent relapses is a prominent characteristic of 
otitic inflammations in infancy and childhood. After the tenth to the 
fifteenth year of age this tendency is not so marked. 



752 THE EAR 

Treatment. — The treatment is almost the same as in adults, with 
the exception that tympanic inflation is usually followed by great relief. 
When the inflammation is suppurative in character, the external meatus 
should be thoroughly cleansed with cotton- wound probes. The same 
treatment described under Acute Suppurative Otitis Media and Acute 
Mastoiditis is applicable to these cases. The removal of adenoids, when 
present, is usually followed by great improvement or a cure of the 
otorrhea. Many cases of chronic otorrhea in children cease after the 
removal of the adenoids. If, however, the otorrhea is secondary to scarlet 
fever, measles, or diphtheria, it is often necessary to perform a mastoid 
operation to effect a cure. If nystagmus and meningeal symptoms were 
present, the case should be carefully watched and free drainage main- 
tained, and, if necessary, suitable surgical procedures adopted. 



CHRONIC SUPPURATIVE OTITIS MEDIA 

Owing to the faulty instruction, or, more properly speaking, to the 
lack of systematic instruction in otology in most American medical col- 
leges, false ideas are prevalent concerning the true importance of chronic 
suppurative otitis media. The acute exacerbation is the only phase 
that ordinarily attracts serious consideration. When we recall the fact 
that none of the prominent life insurance companies will accept an appli- 
cant who is affected with chronic or intermittent otorrhea, we are brought 
face to face with the business man's view of the disease. He has found 
after a careful study of the mortality tables, that applicants thus affected 
do not live to the full term of their natural lives. Both clinical observation 
and pathological findings bear out this conclusion. Clinically, we find 
chronic otorrhea attended with a sallow, muddy complexion and acute 
exacerbations, during which there is pain and mastoid tenderness, and an 
increased flow of pus, which subsides only to return again after many 
weeks, months, or years. In other cases, sinus thrombosis, septicemia, 
labyrinthitis, meningitis, brain abscess, etc., which often lead to a fatal 
termination, are associated. Bearing these facts in mind, and their 
relation to what seems to be a simple and harmless chronic otorrhea, 
it becomes apparent that chronic suppurative otitis media is not to be 
thought of as a trivial or an unimportant disease. 

Symptoms. — The symptoms vary with the nature and location of 
the pathological process, as well as with its acuteness or chronicity. 
In some cases the signs of the ear disease are so latent that but little 
thought and less attention are given to them. In others, there is a 
constant or intermittent flow of pus or mucopus into the external canal, 
with occasional twinges of pain. In still others, there are acute exacer- 
bations, characterized by profuse pus discharge, often admixed with 
blood, and attended with pain, mastoid tenderness, and swelling. The 
chief difference between the types is in the degree of obstruction to free 
drainage and in the virulency of the microorganisms in the tympanic 
cavity and mastoid cells. So long as there is free drainage, and there are 



CHROXIC SUPPURATIVE OTITIS MEDIA . 753 

no virulent microorganisms jeopardizing the middle-ear and cranial 
contents, the symptoms are not alarming in character. On the other 
hand, when free drainage is interfered with and virulent infection 
supervenes upon the preexisting less virulent infection, the symptoms 
assume a most aggravated and alarming character. In other words, 
the so-called chronic suppurative otitis media assumes the proportions 
of an acute mastoiditis with threatened intracranial complications. 

The Latent Form. — The symptoms in this type of middle-ear suppura- 
tion are scarcely appreciable to the patient, as there is little discharge 
and no pain or tenderness over the mastoid process. The patient often 
says there is no discharge, nor has there been for many months or years. 
Ocular inspection, however, will often show a small amount of pus 
in the middle ear and external auditory meatus. The amount is so 
small that it does not reach the concha, but is evaporated in the meatus, 
the dried remains being thrown off with the cerumen and epidermis. In 
these cases there is a central perforation of the drumhead, the size 
varying from a millet-seed to almost the entire membrane (pars tensa), 
though frequently cases of latent otorrhea are observed in which the 
perforation is marginal. 

The Chronic Discharging Form. — There is a profuse but intermittent 
purulent discharge, sometimes admixed with mucus and blood. Acute 
coryza, epipharyngitis, and exposure to inclement weather increases the 
amount of discharge and its purulency. Pain may be present, espe- 
cially when aggravated by either of the foregoing conditions. There is, 
at these times, a slight tenderness over the mastoid process, especially 
over the antrum. Inspection of the fundus meati shows pus completely 
filling it, or oozing through the perforation in the drumhead. If the 
drumhead is largely destroyed, and the pus has its origin in the attic, it 
may be seen to trickle down the long process of the incus into the atrium 
of the middle ear. After removing all the pus from the middle ear, the 
promontory appears as a yellowish-red reflex. Granulations or polypi 
may be present, filling the middle-ear cavity, or even protruding into 
the external meatus. 

I have seen cases in which the polypus protruded into the choncha of 
the auricle. When polypi are present, blood is often admixed with the 
secretions. 

There is more or less elevation of temperature during the subacute 
exacerbations. The skin is yellow and muddy, the whites of the eyes 
are slightly discolored, and a feeling of lassitude and mental inertia 
possesses the patient. 

Chronic Otorrhea with Acute Exacerbations. — This form of chronic sup- 
purative otitis media attracts attention on account of the exacerbations 
of pronounced pain, mastoid tenderness, and elevation of temperature. 
The patient and attending physician become conscious of the danger, 
which may have existed for some weeks, months, or even years pre- 
viously. What was previously regarded as a simple harmless discharge 
is now recognized as a threatened mastoiditis. There is a profuse 
flow of pus, perhaps admixed with blood, the mastoid is tender to the 

48 



754 



THE EAR 



touch, either at its tip or over the antrum, and the temperature ranges 
from 1° to 4° above normal. There may be no distinct chill. 

The patient complains of lassitude, and is disinclined to pursue his 
vocation. He may be apprehensive of impending danger. 

Having thus characterized the more obvious symptoms of the three 
most common types of chronic suppurative otitis media, the further study 
of the signs of this disease, and their significance in estimating the nature 
and location of the pathological changes, will be based upon the location 
of the perforation in the drumhead. 

Fig. 417 




The significance of central and marginal perforations of the membrana tympani. 



Perforations, their Location and Significance.— To Leutert, Zaufal 
and others we owe our knowledge of the pathological significance of the 
location of the perforations in the drumhead. It may be said, in gen- 
eral, that if the perforation is marginal, there is bone necrosis in the 
region of the perforation; and if the perforation does not involve the 
margin of the drumhead, but is near its centre, bone necrosis is absent, 
the case being one of simple suppurative otitis media. The informa- 
tion thus afforded, while not absolute, is nevertheless very valuable in 
arriving at a full knowledge of the case. 

The Clinical Significance of Chronic Perforations of the Mem- 
brana Tympani.— A central perforation (Fig. 417, a, b, c) usually sig- 
nifies inadequate drainage and ventilation through the Eustachian tube, 
the perforation occurring at the point of least resistance. A central per- 



CHRONIC SUPPURATIVE OTITIS MEDIA 755 

f oration is rarely attended with necrosis of the bony walls of the cavum 
tyinpani or of the ossicles, and may be successfully treated without 
major surgical interference. According to Leutert, all central perfora- 
tions indicate tubal infection. 

(c) This is a central perforation (Fig. 417), located over the tympanic 
orifice of the Eustachian tube, and is the result of continual middle ear 
infection from the tube. The Eustachian tube is probably infected from 
the epipharyngitis, if present. The epipharyngitis may be due to the 
presence of adenoids or their remnants, or to diseased tonsils, or to 
ethmoiditis and sphenoiditis. A perforation of the membrana tym- 
pani over the tympanic orifice of the Eustachian tube should, therefore, 
direct the attention of the aural surgeon to the epipharynx and the con- 
tiguous structures, rather than to the tympanic cavity. A radical 
mastoid operation upon a case with a perforation at this point would, in 
all probability, fail to check the otorrhea. An attempt to close the tym- 
panic orifice of the Eustachian tube at the time of the radical operation 
would, in all probability, meet with failure, as the continued infection 
from the epipharynx would prevent closure. The rational treatment 
of such a case would be to cure the sinuitis, remove the adenoids and 
tonsils, or to adopt such other remedial measures as will cure the epi- 
pharyngitis. 

A perforation of the inferior margin of the membrana tympani (Fig. 
417, d) signifies necrosis of the inferior wall or floor of the tympanic 
cavity. The only vital structure in this region is the jugular bulb. As 
the bony wall separating the tympanic cavity and the jugular bulb is 
usually quite thick, the perforation may signify nothing more than 
necrosis of the floor of the tympanic cavity, a region which is accessible 
to curettement through the external meatus. In rare instances, however, 
the jugular bulb is separated from the tympanic cavity by only a thin bony 
wall, or the wall may be entirely absent. A marginal perforation at this 
point should, therefore, be regarded as suspicious of necrosis from jugular 
bulb disease, especially if septic symptoms are present. The exploration 
and curettement of the floor of the tympanum should in such cases be 
prosecuted with caution. 

A perforation of the membrana flaccida immediately above the 
short process of the malleus (Fig. 417, e) usually signifies necrosis 
of the head of the malleus, a structure in close apposition to the per- 
foration. 

A marginal perforation immediately above the short process of the 
malleus and extending to the superior wall of the meatus (Fig. 417, /) 
usually signifies necrosis of the tegmen tympani (roof of the attic). 

A perforation of the membrana tympani at the margin of the pos- 
terior quadrant of the membrana tympani (Fig. 417, g) usually signifies 
necrosis of the incus and of the walls of the antrum. 

Numerous small perforations near the margin of the membrana 
tympani (Fig. 417, h) are usually significant of a tuberculous otitis 
media. 

From the foregoing data it may be inferred that a central perfora- 
49 



756 THE EAR 

tion signifies a simple infectious process in the cavum tympani, probably 
of tubal origin, whereas a marginal perforation usually signifies bone 
necrosis. Marginal perforations are, therefore, indicative of a more 
serious process in the middle ear (cavum tympani) than is indicated 
by a central perforation. The entire absence of the membrana tympani 
is equivalent to a marginal perforation, and is strongly suggestive of 
bone necrosis. 

AYhile the significance of chronic perforations is generally to be inter- 
preted as given in the foregoing paragraphs, it should not be inferred 
that the location of the perforation is an infallible guide to the condi- 
tion present in the middle-ear and mastoid cavities. All other clinical 
phenomena should be taken into consideration, and a conclusion be 
drawn from the entire symptom complex. 

Prognosis as to Hearing. — In simple or central perforations the hear- 
ing may be but slightly affected after the suppurative process is re- 
lieved. In the complex or marginal perforations, with bone necrosis, 
the hearing is usually diminished after the radical operation, whereas it 
is greatly improved after the meatomastoid operation. The patient 
should be made to understand that, while every effort will be made to 
maintain or improve the hearing, the chief concern is to check, or to 
cure, the suppurative process, which, if allowed to run its course, may 
jeopardize both the health and life of the patient. 

According to Clarence Heath, of London, many of the cases hereto- 
fore operated by the radical method may be cured by a less radical 
operation. (See Meatomastoid Operation.) In addition to a less 
radical procedure, he claims that the hearing is not only conserved, 
but that it is usually restored to near the normal. The author's ex- 
perience with the meatomastoid operation is limited to twenty-five 
cases, and thus far the results obtained have been excellent. The 
twenty-five cases selected for this operation have been those in which 
the ossicles were not markedly necrosed, though the perforation in some 
was marginal. The prognosis as to the permanent cure of the disease 
by this operation is still open until further experience demonstrates 
its exact place in otological surgery. That the hearing is temporarily 
preserved, and usually greatly improved is fairly well demonstrated. 

Treatment. — The treatment of chronic suppurative otitis media 
does not offer a brilliant therapeutic field. In spite of all that can be 
done with local treatment, the discharge often persists, or, if checked, 
recurs within a few weeks or months. Many so-called "cured cases" 
are in reality only latent, and with the first "cold in the head," or other 
local irritation, become active again. This tendency is so strong that 
many otologists have regarded the persistence, or the tendency to recur- 
rence, as an indication for the radical mastoid operation. While this is 
probably an extreme view, it is, nevertheless, a more rational one than 
the view held by some, that most cases of chronic otorrhea may be cured 
by simple local treatment, or by simple operative measures through the 
external auditory meatus (Hotz, Theobald). As a matter of fact, each 
case should be diligently studied as x o the local morbid conditions, and 



CHRONIC SUPPURATIVE OTITIS MEDIA 757 

as to the main etiological factors. Furthermore, the pathological laws 
underlying infectious processes in cavities lined with mucous membranes 
should be well considered. (See Chapter VI.) 

The treatment of chronic suppurative otitis media will be studied, 
with the foregoing facts in mind, under the following headings 

The Treatment of Chronic Otorrhea with a Central Perforation cf the Mem- 
brana Tympani. — Chronic suppurative otitis media with a central perfora- 
tion of the membrana tympani (Fig. 417, a, b, c) usually signifies a simple 
infection of the mucous membrane of the Eustachian tube and middle 
ear without involvement of the bony tissue of the tympanic walls, or 
of the ossicles, and is, therefore, often amenable to simple local treat- 
ment. Non-marginal perforations indicate a suppurative process in 
the Eustachian tube, hence the middle ear cannot be cured while the 
tubal infection continues. In such cases the first attention should 
be given to the Eustachian tube and the conditions giving rise to its 
involvement. 

The otorrhea is perpetuated by the discharge of infected secretion from 
the Eustachian tube into the tympanic cavity, and cannot be cured with- 
out first overcoming the infection and discharge from this source. The 
mucous membrane of the Eustachian tube, when normal, is covered by 
ciliated columnar epithelium, which propels the secretions toward the 
pharyngeal orifice of the tube. In chronic infectious processes the cilia 
are lost, or their wave-like motion is inhibited, and the secretions flow 
in the direction of least resistance. The isthmus of the tube forms a 
partial barrier to the downward flow of the secretions from the tympanic 
end of the tube, hence they are retained in the tympanic cavity. The 
constant irritation of the membrana tympani opposite the tympanic orifice 
of the tube leads to perforation at this point. The first indication in these 
cases is to remove the cause of the tubal infection and inflammation. 

If the tubal infection is due to a constriction at the isthmus of the tube, 
the tube should be dilated with bougies, and astringent and antiseptic 
solutions forced through it with a Weber-Liel catheter. 

If the infection is due to the presence of epipharyngeal adenoids, 
or their remnants, they should be removed. 

If the infection is due to an epipharyngitis, it should receive appro- 
priate treatment. 

Finally, if the tube is infected by the discharge from diseased nasal 
sinuses, especially the posterior ethmoidal and sphenoidal sinuses, this 
condition should receive appropriate treatment. 

Having removed the cause of the tubal infection, that in the tympanic 
cavity tends to disappear with little or no other treatment. In some cases, 
however, the infectious process in the Eustachian tube is attended by 
such pronounced tissue changes that additional local treatment of the 
middle ear is necessary. 

Removal of Adenoids. — If adenoids are present, it may be assumed 
that the ear disease cannot be permanently cured until they are removed ; 
hence, the first indication is to remove them and then address the treat- 
ment to the ears. The tonsils may also require attention. 



758 THE EAR 

Epipharyngitis. — Epipharyngitis is usually caused by adenoids, hence 
the adenoids should be removed and the epipharyngitis treated with 
weak silver solutions. When overcome, address the treatment to the 
middle ear and Eustachian tube. 

Sinuitis. — Chronic posterior ethmoidal and sphenoidal infection cause 
swelling and infection of the Eustachian tubes and thus perpetuate 
middle-ear infection. Give appropriate attention to these conditions 
and then direct the treatment to the ears. 

If the above courses of treatment are consistently pursued, many cases 
may be cured without a mastoid operation. 

Dry Gauze Dressings. — In 1880-82, Dr. Spencer, of St. Louis, ad- 
vocated the use of strips of dry gauze in the treatment of acute and 
chronic suppurative otitis media. Since then the same method of treat- 
ment has been urged by Gradinego, Pierce, Gradle and others. 

The fundus of the meatus should be mopped dry with a cotton-wound 
applicator before the strip of gauze is applied. 

The end of the gauze is then carried to the membrana tympani with a 
probe packer (Fig. 418). The meatus is then loosely packed with the 
gauze and a small piece of cotton placed over it. The gauze should be 
removed every twenty-four hours and the secretions thoroughly removed 
with a cotton- wound applicator. A new strip of gauze is then applied 
as before. 

Fig. 418 



F.A.HARDY &C0. 

Bane-Allport gauze packer. 



In some cases the drainage and protection afforded by the gauze leads 
to the rapid disappearance of the infection and to repair, the perfora- 
tion often voluntarily closing by granulating from its edges. In other 
cases it persists, and may be closed by the application of a 33 per cent, 
solution of trichloracetic acid to its edges at intervals of a few days. 
No attempt should be made to close the perforation until the secretion 
is normal. 

In addition to the foregoing method of treatment, alcohol in varying 
strength may be instilled into the middle ear through the meatus. 

The middle ear may also be cleared by inflation through the Eusta- 
chian tube if the otorrhea persists after several treatments. 

Treatment via Weber-Liel Catheter.— The local treatment of the 
infected Eustachian tube and tympanic cavity consists in the use of 
the dry gauze treatment and in the use of mild astringents and anti- 
septic solutions through the Eustachian tube, a Weber-Liel catheter 
being used for this purpose. The Weber-Liel catheter consists of a 
small, long, flexible rubber catheter, placed inside of a larger catheter 
of the usual length. The larger catheter is passed to the pharyngeal 
orifice of the tube, and the smaller one is introduced through it to the 
isthmus of the Eustachian tube. A small syringe filled with an alka- 
line antiseptic solution is then attached to the smaller catheter and 



CHRONIC SUPPURATIVE OTITIS MEDIA 759 

the fluid forced into the middle ear. This course of treatment, fol- 
lowing the removal of the conditions causing the tubal and middle- 
ear infection, is often attended by a complete cure of the chronic 
otorrhea. 

Treatment of Chronic Otorrhea with Marginal Perforations of the 
Membrana Tympani. — As marginal perforations of the membrana tym- 
pani usually signify necrosis of the ossicles, the bony tympanic walls, 
the tegmen tympani or tegnien antri, and the other contiguous bony 
structures, the treatment of chronic otorrhea thus characterized is 
not as simple as in central perforations. The same fundamental 
principles of treatment should, however, be observed. The drainage 
and the removal of the morbid material are absolutely essential to 
success. 

The methods of establishing drainage and of removing the morbid 
material are radically different, for anatomical and pathological reasons, 
from those pursued in otorrhea with central perforations. It is obviously 
impossible to materially facilitate drainage by dressings in the external 
auditory meatus when the obstruction is in the antrum or aditus ad 
antrum. It is equally obvious that the morbid material cannot, under 
such conditions, be removed through the auditory meatus. Surgical 
measures are usually required in these cases, as follows : 

1. When the perforation is just above the short process of the malleus 
(Fig. 417. e), the head of the malleus is probably necrosed, and the 
malleus should be removed. (See Ossiculectomy.) A 2 per cent, solution 
of the nitrate of silver may, however, be injected through the perforation 
to promote healthy granulation, with the hope of healing the diseased 
ossicle and thus avoiding the necessity of removing it. 

2. When there is a perforation at the upper margin of the membrane 
(Fig. 417, /), and it involves not only the membrana flaccida but the 
superior wall of the auditory meatus, the tegmen tympani is probably 
necrosed. Even in these cases, ossiculectomy is sometimes attended by a 
cure of the chronic infection and otorrhea. If the floor of the attic is 
blocked, the removal of the malleus and incus may establish free drain- 
age, and thus effect a cure. In other instances, ossiculectomy will not 
effect a cure, probably because the case is complicated by epipharyngitis, 
salpingitis, or necrosis of the antrum walls. Ossiculectomy is, there- 
fore, only applicable to those cases in which the tegmen tympani is alone 
necrotic, the complicated cases being amenable to the meatomastoid and 
the radical operations. 

3. When the chronic otorrhea is attended by a marginal perforation 
at the postsuperior quadrant of the membrana tympani, as shown in 
Fig. 417, g, necrosis of the antrum is probably present. The incus also 
may be necrosed. To establish drainage, and to remove the morbid 
material, either the radical or the meatomastoid operation should be 
performed. It is barely possible, however, that by irrigating the attic 
through the perforation, drainage may be established through the aditus 
ad antrum and a cure effected. To these cases the meatomastoid opera- 
tion appears to be well adapted. 



760 THE EAR 

4. With a perforation at the inferior margin of the membrana tym- 
pani (Fig. 417, d), the necrosed bone may be removed with a curette 
introduced through the auditory meatus. If septic symptoms are 
present, the floor of the tympanic cavity should be cautiously explored, 
as the necrosis may be due to an extension from the jugular bulb. If 
septic symptoms are present in such a case, the rational procedure would 
be to perform either the radical or the meatomastoid operation, and 
then expose the sigmoid portion of the lateral sinus and the jugular 
bulb. If septic symptoms are absent, the floor of the tympanum should 
be explored with a blunt probe for necrotic bone, and if found, it should 
be carefully removed through the perforation with a bent curette. The 
perforation should be previously enlarged by two divergent incisions. 
After curettement, the meatus should be loosely packed with sterile 
gauze, as recommended in simple central perforations. The gauze 
should be removed daily, the meatus freed of secretions, and repacked 
with gauze, until the necrotic area is healed and the perforation closed. 
If the secretions disappear and the perforation persists, the perforation 
may be closed by the application of a 33 per cent, solution of trichlor- 
acetic acid to its margins. 

5. Otorrhea attended by a perforation of the membrana tympani at 
its anterior margin usually signifies necrosis in this region. As the 
carotid artery passes upward through the temporal bone near the ante- 
rior boundary of the cavum tympani, curettement should be cautiously 
performed in this region (Fig. 417). (See Surgical Treatment.) 

Other Methods of Treatment. — Curettage of the attic via the external 
auditory meatus should be undertaken with great reluctance and cau- 
tion. If granulations are present, it is quite probable that the tegmen 
tympani is necrosed and that the granulations are thrown around and 
over it to wall off the invading pathogenic bacteria from the meninges. 
The removal of the granulation tissue without at the same time estab- 
lishing free drainage of the secretions from the tympanic cavity might 
lead to infection of the meninges. Such a condition may be much more 
successfully, safely, and conservatively treated by either the radical or 
the meatomastoid operation. 

The alcohol treatment has been held in high esteem in chronic suppu- 
rative otitis media. Its field of usefulness is chiefly limited to central 
perforations, especially after the causes of the tubal infection have been 
removed (see p. 757). 

In otorrhea with a marginal perforation, alcohol only relieves the 
symptoms, but does not cure the disease. 

The alcohol may be used in various dilutions, ranging from 25 to 95 
per cent., beginning with the milder solution and gradually increasing the 
strength. The alcohol should be left in the cleansed ear for twenty 
minutes at each treatment. 

Alcohol holding boric acid or iodoform in solution or suspension may 
be used in otorrhea with a central perforation, though it is probable 
that its therapeutic value is not increased by the addition of the boric 
acid or iodoform. 



CHOLESTEATOMA 761 

In fetid otorrhea the instillation of the compound tincture of benzoin 
may be used to remove the fetor. It is also an antiseptic and astringent, 
and acts favorably upon the diseased tissues. The fundus of the 
meatus should be mopped dry before applying the compound tincture 
of benzoin. 

AYhen there are exuberant granulations in the middle ear, a 95 per 
cent, solution of carbolic acid may be applied, care being exercised to 
prevent the acid coming into contact with the meatal skin. At the 
expiration of one minute, alcohol should be instilled into the ear to 
check the action of the acid, after which the ear should be mopped with 
a cotton-wound applicator. The meatus should then be loosely packed 
with dry, sterile gauze. 



CHOLESTEATOMA 

Cholesteatoma of the middle ear is characterized by the formation of 
masses of epidermoid cells arranged in concentric layers, between which 
are found cholesterin crystals. 

Etiology. — About the year 1840, J. Miiller described new formations 
in the temporal bone, resembling pearly growths. They were composed 
of concentric layers of epidermoid cells with cholesterin crystals between 
them. They are commonly found in the atrium and attic, and are 
covered with a delicate membrane which is closely adherent to the peri- 
osteum of the bone to which they are attached. This variety is known as 
primary cholesteatoma, as it seems to have its origin in the cavity where 
it is found. The secondary and most common type is due to an exten- 
sion of the epidermis of the external meatus and membrana tympani 
into the middle ear through a perforation in the drumhead. 

Primary Cholesteatoma. — Primary cholesteatoma is variously believed 
to be heteroplastic, possibly arising from the epithelium of the ductus 
vestibule; that is, it is a remnant of the second visceral cleft left behind 
after its closure. Mild inflammatory action in the middle ear favors its 
growth, whereas severe inflammation hinders it. Primary cholesteatoma 
is probably quite rare. Its existence might well be doubted if it were not 
for the fact that eminent observers have made full and detailed reports 
of such cases. Other equally eminent observers claim there is no such 
condition, all cases being secondary to suppurative processes in the 
tympanic cavities. Von Troltsch, Habermann, Politzer and others hold 
this opinion. 

Secondary Cholesteatoma. — This is the type found in practice, the 
primary form being chiefly limited to literature. The masses in all 
probability have their origin from extensions of epidermis from the 
external meatus and drumhead. The conditions favoring this extension 
are: 

(a) A marginal perforation of the drumhead. 

(b) A mild chronic suppurative inflammation of the mucosa of the 
middle ear. 



762 THE EAR 

(c) A fistulous opening in the posterior or superior wall of the meatus. 

(d) Adhesions at the margin of the perforation. 

(e) Adhesion of the end of the handle of the malleus to the promontory. 
(/) Aural polypi. 

Perforations in the posterior portion of the membrana flaccida are 
especially liable to be followed by cholesteatoma on account of the tongue- 
like thickened extension of epithelium from the superior wall of the 
meatus to the drumhead at this point. Politzer reports a case in which 
the growth seemed to have its origin in a fistulous opening in the mastoid 
process. 

The cholesteatomatous masses are of a pearly gray color, and slightly 
lustrous. Upon section they are found to be composed of concentric 
layers of epidermic cells intermixed with detritus and cholesterin crystals. 
If the conditions are favorable, the masses grow larger and larger, and 
cause eccentric pressure atrophy of the bony walls of the cavity involved. 
In some cases the bone is necrosed, exposing the brain, lateral sinus, 
and labyrinth. The masses are broken down in their centres, richly 
odorous, and loaded with pathogenic microorganisms. The central 
breaking down is due to putrefaction. 

Aural polypi, with mild suppurative inflammation, are often attended 
with cholesteatomatous formations. If there is an active or profuse 
pus discharge, the growths are checked or altogether dissipated. The 
free drainage incident to a profuse discharge seems to prevent the further 
inward extension of the epidermic process, the masses gradually dis- 
appearing, and the cavity healing with a layer of flat epithelial covering 
or matrix. The size of the cholesteatomatous masses varies from a 
hemp-seed to a large walnut. Their shape either conforms to that of the 
cavity in which they form, or they are round, oval, or very irregular in 
outline. 

Extensions of the cholesteatoma into the Haversian canals have been 
demonstrated, which may, in part, account for the marked tendency to 
recurrences in spite of thorough operative interference. E. B. Dench has 
called attention to the presence of small masses of cholesterin crystals 
without epithelial cells, the etiology and pathology of which are not 
known. He reported two such cases operated by the radical method, 
with good results. 

Symptoms. — The masses may be present for years without giving 
rise to distinct symptoms. Sudden swelling of the mass from the en- 
trance of moisture into the external meatus, as from sweating, bathing, 
syringing, etc., may cause pressure symptoms, as pain and necrosis. 
In this there may be a feeling of fulness or pain in the affected ear, with 
headache, nausea, vomiting, nystagmus, staggering gait, fever, and apro- 
sexia. The moisture causes the horny cells to swell, and the sudden 
pressure thus exerted causes the above signs of pressure and of intra- 
cranial irritation. 

Inspection of the meatus shows it to be more or less filled with a pearly 
gray mass, admixed with granulations or aural polypi. If a portion is 
removed and placed in water, it appears as shreds of delicate tissue 



CHOLESTEATOMA 763 

with the golden grains of cholesterin, which are characteristic of this 
growth. If the mass is favorably located, it may be removed with the 
syringe or ear spoon. In other cases it is necessary to resort to the radical 
mastoid operation. Even then it may be necessary to repeat the opera- 
tion one or more times before a satisfactory result is obtained. 

The termination of cholesteatoma may be (a) by epidermization after 
the spontaneous or instrumental removal of the mass; (6) by forcing 
it through the Eustachian tube into the epipharynx, or into the maxil- 
lary articulation through the anterior wall of the meatus; (c) by its 
breaking through the walls of the semicircular canals (Jansen); (d) 
in some cases by pushing its way through the external plate of the 
mastoid process and presenting the appearance of a mastoid abscess; 
(e) in still other cases by causing necrosis of the tegmen antri and 
tympani and causing death from involvement of the cranial contents; 
(/) sepsis arising from the absorption of the retained secretions, causing 
death; (g) and from meningitis, brain abscess, sinus thrombosis, or 
thrombosis of the jugular vein with a similar result. 

Diagnosis. — The diagnosis may be made by the removal of the growth 
and subjecting it to microscopic examination. It may be removed with 
a curette, probe, or syringe when the growth is in the middle ear. If in 
the antrum, it can only be removed by a mastoid operation. Sydacker 
has called attention to the sedimentation of the washings of the ear, 
which, when microscopically examined, show the epithelial cells with 
nuclei staining very faintly. Particles of bone dust are also shown as 
highly refractile crystals. Bruhl and Politzer have called attention to the 
use of a chloroform solution of the cholesteatomatous masses in which 
the cholesterin produces a greenish discoloration. 

Prognosis. — The prognosis is bad. In those cases in which there is a 
spontaneous or instrumental expulsion of the cholesteatoma, the cavity 
usually becomes refilled. Even after the most thorough radical opera- 
tion, the disease may persist. This is not at all difficult to understand 
when we recall the fact that the cholesteatoma forces its way into the 
Haversian canals of the bone, thus effectually forming focal centres 
from which it may extend again. Sac-like prolongations into the bone 
have also been observed, thereby making it difficult to entirely eradicate 
the process. The uncertainty of cure leaves the possible complications, 
as meningitis, brain abscess, pyemia, sinus and jugular thrombosis, 
a menace to the health and life of the patient. A cure is, however, 
usually effected, and we are warranted in attempting thorough surgical 
measures for its relief. 

Treatment. — The treatment in uncomplicated cases may be begun 
by the removal of the cholesteatoma through the perforation in the 
drumhead with small curettes, ear hooks, etc., or with a syringe. In 
some instances it is found to be advantageous to force sterile fluid through 
the Eustachian tube into the middle ear, thus getting the force of the 
stream of water behind the mass, and forcing it into the external meatus. 

Should polypi be present, they should be removed. If there is necrosis 
of the ossicles, they should be removed. Adhesion of the edges of the 



764 THE EAR 

perforation to the inner wall of the tympanum or adhesion of the end 
of the handle of the malleus to the promontory should be overcome. 
After having removed the tumor the parts should be dusted with an 
antiseptic powder. 

Should these simple measures prove ineffective, recourse must be had 
to the radical mastoid operation, elsewhere described in this work. The 
meatomastoid operation is not indicated, as the chief object of this 
operation is to preserve or improve the hearing. In these cases this 
object is defeated by the unavoidable dislocation of the ossicles in 
removing the cholesteatoma. 



CHAPTEK XLIV 

THE SEQUELAE OF SUPPURATIVE OTITIS MEDIA, MASTOIDITIS 
AND CHOLESTEATOMA. SUPPURATION OF THE LABYRINTH 

DISEASES OF THE MASTOID PROCESS 

Primary infection and inflammation of the mastoid process is very 
rare. Disease of the mastoid is usually secondary to a suppurative 
process in the middle ear, but there are cases of pneumococcus, and more 
especially influenza infection, which sometimes appear in the mastoid 
process without first affecting the middle ear. As a matter of fact, 
all, or nearly all, suppurative middle-ear inflammations probably also 
involve the mastoid cells. 

It is difficult to separate the suppurative processes of the middle ear 
from those of the mastoid cells. Clinically, the disease is subdivided upon 
an arbitrary basis according to the focal manifestations present. The 
anatomical distribution of the pneumatic spaces of the temporal bone is 
so complex that it is advantageous to subdivide suppurative inflamma- 
tions within them according to the focal centre of involvement, while, 
on the other hand, it is more rational to regard the process as one disease 
regardless of the focal symptoms. The antrum is perhaps the axial 
centre of the pneumatic spaces of the ear, the mastoid cells communi- 
cating with it, while the attic and atrium (middle ear) communicate with 
it anteriorly through the aditus ad antrum. If the case requires external 
surgical treatment, it is most centrally attacked by way of the antrum, 
the operative field being extended posteriorly into the mastoid cells and 
anteriorly into the middle ear, according to the conditions present. If 
the disease is focalized in the middle ear without mastoid symptoms, it 
may be regarded as middle-ear disease. In those acute cases termin- 
ating without focal mastoid symptoms, it has been customary to speak 
of them as acute otitis medias, regardless of the fact that the mastoid 
cells were also involved. 

With this understanding, the various diseases of the mastoid process 
will be described. 



ACUTE SIMPLE MASTOIDITIS WITHOUT INTRACRANIAL LESIONS 

Symptoms. — It is probable that in nearly every case of acute infection 
of the middle ear, the mastoid cells and antrum are also involved. It 
is chiefly in those cases in which free drainage is interfered with that 
the mastoid symptoms become manifest. These symptoms are chiefly 

(765) 



766 THE EAR 

those of pressure from retention of the secretions within the cells. They 
are pain, redness, swelling, and tenderness upon pressure or percus- 
sion over the mastoid process. When such symptoms supervene, the 
original disease sinks into a place of secondary importance, while the 
secondary condition comes forward as the object of greatest interest. 
The disease is nG longer called otitis media, but is called mastoiditis. 

There is a sudden rise of temperature accompanied by rigors of 
varying intensity. Many cases, however, have but slight elevation of 
temperature at any time during the disease. In others, the rise is as 
high as 104° F. 

The pain originates behind the auricle and radiates toward the teeth 
and shoulders (Politzer), the occiput, neck, and face. Mastication may 
be painful on account of an involvement of the bony portion of the 
external meatus, which is in close proximity to the glenoid fossa 

The sternocleidomastoid and the other muscles of the neck attached 
to the mastoid account for the pain upon movements of the head. Torti- 
collis may be present, and is due to a fixation of the muscle to avoid 
pain upon movement. It has been shown by others (Broca and Lubet- 
Barbon) that it is sometimes due to enlargement of the cervical glands 
and to infection from measles, in which otitis media was not present. 
In measles the torticollis is probably due to glandular enlargement from 
infection. 

Schwartze called attention to the intolerance of pressure over the whole 
mastoid, but more particularly immediately below the zygomatic ridge 
(antrum), as a symptom of mastoiditis. 

The skin over the mastoid process may become red and swollen. In 
some cases the auricle stands forward, even approaching a right angle to 
the side of the head. In these cases a subperiosteal abscess is present. 

The aural discharge may be scanty or profuse. Redness and swelling 
of the posterior wall of the external meatus near the drumhead are 
commonly present. This condition is variously spoken of as the "dip," 
"chute," or "bulging" of the postsuperior wall. Under the pathology 
of the mastoid reference has already been made to the presence of pneu- 
matic mastoid cells (the border cells), which are found between the 
antrum and meatus. These break down, and the retained secretions 
cause the wall to thus "dip" or "bulge." This sign is pathognomonic of 
mastoiditis of a destructive type, and is, therefore, a strong indication 
for an immediate operation. 

The diagnostic value of this sign has been emphasized by Schwartze, 
Mace wen, Holmes, Sheppard, Duplay and many others. Politzer 
thinks it is not necessarily an indication for the mastoid operation, while 
Schwartze, Broca, and Lubet-Barbon hold the contrary view. 

Delay in operating subjects the patient to almost certain danger, even 
though it does not become apparent for years. The author can recall 
but one case (following an attack of influenza) in which the "dip" and 
all other signs of middle-ear and mastoid disease seemed to disappear. 
The word "seemed" is used advisedly, for there is little doubt as to a 
subsequent recurrence in such cases. There are exceptions to all rules 



ACUTE MASTOIDITIS WITHOUT INTRACRANIAL LESIONS 767 

and the case just mentioned was probably one of them. Nevertheless, 
the rule and not the exceptions should guide us. 

A central perforation of the drumhead nearly always exists. It is 
usually small and filled with pus and debris, which pulsates synchro- 
nously with the heart beat. Should the infection be very intense, great 
destruction of tissue may result, in which event the perforation may be 
marginal. 

Granulations sometimes protrude through the opening and block 
the discharge of the secretion. The removal of the granulations is often 
sufficient to establish free drainage and relieve the acute mastoid symp- 
toms. It may be doubted whether it really cures the mastoiditis, as this 
may remain in a latent form for years before culminating in an alarming 
exacerbation. 

In still other cases the perforation is large and discharges but little 
pus. In these cases the aditus ad antrum is obstructed, and pain is 
pronounced. This is of interest as a diagnostic and prognostic point. 
It enables the attending physician to locate the obstruction prior to the 
operation, and to determine whether relief may be expected from a 
simple middle-ear operation (incision of the membrana tympani) or 
whether it will be necessary to perform a postauricular mastoid operation. 

Spontaneous cures should be looked upon with suspicion, as in nearly 
every case it amounts to nothing more than a remission. Politzer, 
Schwartze, Duplay, Holmes, Ballenger, Stucky, Macewen, Dench, 
St. John Roosa, Hollinger, Pierce, Whiting and many others report 
recurrences in cases which had seemed to be cured. 

One should be extremely modest in claiming to have " cured" mastoid- 
itis without surgical intervention. That such terminations occur cannot 
be denied, but they are rare. 

Treatment. — If the case is seen before spontaneous perforation of the 
eardrum has occurred, the drum should be freely incised at the point of 
greatest bulging. This is done to promote the reaction of inflammation 
and to relieve the pressure and the tissue necrosis. The tissues in the 
presence of an acute infectious process are very susceptible to necrosis 
while pressure is maintained, hence the necessity of an early incision. 
The incision should be a long and curved one, so as to make as free 
an opening as possible. Some writers advise carrying the incision into 
the meatus, thus cutting through the annular plexus of vessels sur- 
rounding the attachment of the membrana tympani. The free bleeding 
thus produced acts favorably upon the progress of the inflammatory 
process; that is, it promotes the reaction of inflammation and favors free 
drainage. Some writers condemn the extension of the incision through 
the annular plexus of vessels, on account of the liability of extending 
the infection through these vessels. If there is a virulent streptococcus 
infection, the incision should not be thus extended, while in the milder 
infections it is safe to do so. The author does not often carry the incision 
into the external meatus. If the destructive process is not great, there 
is no necessity for so doing, whereas if it is great, there are dangers 
attending such a procedure. 



768 THE EAR 

Cold applications by means of an ice-bag or a Leiter coil may be made 
over the mastoid process if the case is seen within thirty-six hours of the 
onset, and if there is great pain and scanty discharge of pus. Cold re- 
duces the inflammatory reaction, diminishes the swelling of the mucous 
membrane, and thus overcomes the obstruction to the flow of the secre-. 
tions. If these applications fail to remove the tenderness and pain, and 
to establish a better discharge of secretions, they should be discon- 
tinued and leeches applied. Leeching is much more efficacious than 
ice. In some cases the cold applications mask the symptoms and lead 
the surgeon to believe the disease is conquered. The real problem in 
acute mastoiditis is not to bring about an abatement of the acute symp- 
toms, but to relieve the patient of the suppurative process by promoting 
the reaction of inflammation. Even though the acute symptoms disap- 
pear and the patient appears to be well, but still has an ear discharge, a 
cure is not effected. Too much attention has been given to the relief of 
the acute symptoms, and too little to the cure of the suppurative process. 
The acute symptoms will usually subside if nothing is done for the patient, 
but in most cases less damage follows if appropriate attention is given 
during their manifestation. Eradication of the suppurative process 
should be the ultimate aim of the treatment. The attending surgeon 
should not be satisfied, therefore, to relieve the pain, redness, tender- 
ness, and temperature, but should also institute such remedial measures 
as will modify the acute symptoms and at the same time eradicate the 
infection. 

To accomplish the foregoing results, it may become necessary to per- 
form a mastoid operation, which, if done at a sufficiently early period, 
need not be an extensive or formidable affair. On the other hand, the 
delay of a few days or weeks may make it necessary to perform a radical 
operation. The cold applications, the incision of the eardrum, leeching, 
etc., should therefore be tried early, so as to determine as quickly as 
possible whether the disease can be aborted. If the mastoid is still tender 
upon pressure and the discharge continues, there is a strong probability 
that the acute process will merge into a chronic one if surgical interference 
is not instituted. The point to be emphasized is that the simple operation 
may be performed within the first three or four weeks of the onset of the 
disease, whereas if delayed to a later period the meatomastoid operation 
may be necessary. There are hundreds of cases of chronic otorrhea 
which would never have existed had they been operated on sufficiently 
early, or had the meatomastoid or the radical operation been performed 
when, on account of delay, a cure by the simple mastoid operation was 
impossible. Just when to operate, and the kind of an operation to per- 
form, is the great problem in acute suppurative otitis media complicated 
by mastoiditis. It should also be stated- in this connection that all cases 
do not need to be operated upon. Many get well without such inter- 
ference. If the pain over the mastoid persists after the incision of the 
membrana tympani and the use of the leeches, an operation is indicated; 
that is, the disease will probably persist as a chronic otorrhea unless an 
operation is performed. The object of the operation is to prevent 



ACUTE MASTOIDITIS WITHOUT INTRACRANIAL LESIONS 769 

further mischief, rather than to avert immediate danger. It is not good 
practice to wait for dangerous symptoms, as the mortality under these 
conditions is much higher. Chronic otorrhea is a signal of impending 
disaster, and every effort should be exerted to prevent it, even though 
a mastoid operation is necessary to accomplish it. 

The Leiter coil should be connected by rubber tubing with a tank or 
bucket of iced water, and the water passed through it by siphonage and 
allowed to escape into a vessel through another tube attached to the 
opposite end of the coil. The iced water should be renewed each time 
the tank becomes empty, and continued for about one hour, or until 
the pain ceases and the purulent discharge becomes more profuse. 

An ice-bag filled with cracked ice, and fastened over the mastoid 
process by bands of linen, may be used instead of the Leiter coil. The 
ice should be renewed as often as it becomes melted. 

Hot irrigations of the bichloride of mercury solution, 1 to 5000, may be 
used every hour to promote the reaction of inflammation. 

Bier's treatment by constriction of the neck, if judiciously applied, 
often exerts a favorable influence upon the course of the disease. The 
patient should be placed in a bed, the foot of which is raised several 
inches from the floor, and an Esmarch elastic band applied around 
the neck. It should produce no pain or discomfort, and only slight 
cyanosis of the face. It should be applied four times daily, with two- 
hour intervals between applications. If the bandage is applied tight 
enough to produce pain, it may do great damage. 

The object of Bier's treatment is to promote the reaction of inflamma- 
tion; that is, to increase the passive hyperemia and the migration of 
leukocytes, so as to remove the bacteria and their toxins. Ice, in view 
of these principles, is usually not indicated, as it diminishes the reaction 
of inflammation. Encapsulated organs, such as the mastoid, however, 
sometimes become so distended by inflammatory swelling that the 
flow of blood through them is very much blocked. Ice relieves the dis- 
tention and establishes the flow of blood, and is indicated under the 
circumstances. When the distention or pressure symptoms (excessive 
pain and scanty discharge of pus) are relieved, ice should be discontinued 
and measures adopted that promote the reaction of inflammation. 

Other methods of promoting the reaction of inflammation are leeches, 
light, heat, hot poultices, etc. (See Chapter VII.) Of these, leeching, 
the leukodescent light, and Bier's treatment are of special value in the 
treatment of acute mastoiditis. 

Leeching should be more generally used, as it is one of the best means 
of promoting the reaction of inflammation. Cases following measles 
running a temperature of 102° to 104°, often rapidly subside after the 
use of leeches. 

Should these simple measures fail, the simple mastoid operation 
should be performed. (See Chapter XL VIII.) 

Subacute Mastoiditis. — This form of mastoiditis has been referred 
to under Acute Mastoiditis as the stage following the subsidence of the 
acute symptoms. It should be regarded as a chronic disease even if 

49 



770 THE EAR 

the conditions present are of recent origin, as it only responds to 
treatment suited to chronic cases. The infectious agent is usually the 
staphylococcus, the usual germ of chronic suppuration. 

Subacute mastoiditis is, therefore, the persistent remains of an acute 
mastoiditis, in which the more active microorganisms have disappeared, 
the staphylococcus perpetuating the inflammatory process. It is amen- 
able to such treatment as is recommended for chronic mastoiditis. 



ACUTE PERIOSTITIS OF THE MASTOID PROCESS; SUBPERIOSTEAL 

MASTOID ABSCESS 

Subperiosteal mastoid abscess is characterized by a pronounced 
bulging outward of the affected ear. The auricle at its superior portion 
stands well out, while its entire free border is almost at right angles to 
the plane of the side of the head. In other words, the outline of the ear 
as seen from either the front or the rear, falls from the upright toward 
the horizontal plane of the head. 

Upon manipulation, the swelling above the auricle fluctuates more or 
less in proportion to the amount of pus beneath the soft tissues. Duplay 
says that before the pus forms externally, one feels the elevation and 
depression, under pressure, of the external table of the mastoid. 

The alarm occasioned by an abscess of this type is out of proportion 
to the danger attending it, as it rarely proves fatal. 

Etiology. — It usually has its origin in an infectious otitis media, which 
extends to the antrum and mastoid cells. In young children, the middle 
ear and antrum alone are involved, as the mastoid cells are not yet formed. 

The periosteum over the squamous portion of the temporal bone is 
more easily separated (Mace wen) than over the mastoid process. In 
consequence, the pus passes upward and causes the outward bulging 
of the upper portion of the auricle. 

Chronic otitis media suppurativa predisposes to the formation of the 
abscess. A low stage of vitality is usually present. It occurs more often 
in children, on account of the loose articulation of the bony plates. 

Treatment. — In acute cases it is often only necessary to make a free 
incision through the skin and periosteum covering the mastoid process 
and evacuate the purulent accumulation. As the abscess is of otitic 
origin, it may in some cases be necessary to perform a mastoid operation 
either at the time of the incision or subsequently. In chronic sub- 
periosteal abscess, the simple incision (Wilde's) may not effect a cure, as 
the ear disease is well established and may require an operation. 



CHRONIC MASTOIDITIS 

Symptoms and Diagnosis. — Chronic mastoiditis is not necessarily 
characterized by any special symptom other than those present in 
chronic suppurative otitis media. Mastoid pain and tenderness and 



CHRONIC MASTOIDITIS 771 

other focal symptoms are often absent. The mastoid bone often under- 
goes an eburnizing sclerosis in the course of the disease, the cortex 
becoming quite dense and the cells replaced by dense bone. It is not 
unusual to find the mastoid process with a few small cells, while the 
remainder of the process is as hard as ivory. In this case, the antrum 
may be smaller than normal. When the cortex is dense, external, 
pressure symptoms are not present. The cranial aspect of the mastoid 
process does not always undergo the sclerosing process; hence, intra- 
cranial complications, as sinus thrombosis, meningitis, brain abscess, 
etc., may be the first focal symptoms to develop. A neuralgic pain often 
accompanies the osteosclerosis of the mastoid process, which may be 
relieved, according to Schwartze, by the removal of a wedge of bone 
from the process. 

The inspection of the drumhead and the middle-ear cavity often 
affords useful information as to the diagnosis. The drumhead is usually 
almost or entirely destroyed. Usually the short process and the head 
of the malleus are present, while the handle is gone. The incus is often 
entirely destroyed, though it may be present in the more recent cases. A 
fetid purulent secretion fills the meatus and the middle-ear cavity. 
When this is removed and suction is applied with Siegle's otoscope, the 
secretion may be seen trickling from the attic into the atrium. After 
the middle ear cavity is thoroughly cleansed, a fetid odor from the 
foul pus which continues to enter the antrum from the inaccessible 
attic and antrum is present, giving evidence of mastoid involve- 
ment. 

Another evidence of chronic mastoiditis is the necrosis or entire de- 
struction of the incus. In the section on perforations of the eardrum, 
attention was called to the significance of a marginal perforation in the 
postsuperior quadrant of the eardrum and the associated necrosis of the 
incus, as signs of necrosis in the antrum. An increased quantity of 
purulent secretion is also a sign of mastoid involvement, although such 
an involvement may be present with scanty discharge. Macewen calls 
attention to the fact that in many cases the discharge is so slight as to 
escape attention. In some of the cases, granulations or polypi are the 
only evidence of mastoid disease. The attachment of the polypi, when 
examined with a delicate curved probe, may be traced to the attic, 
Polypi generally signify bone necrosis. If, after cleansing the atrium 
of all secretions, suction is applied through the Siegle otoscope, and pus 
trickles down one of the fragments of the ossicles, attic and antral 
involvement may be safely inferred. The presence of a persistent puru- 
lent discharge unchecked by local treatment is fairly good evidence 
of chronic otitis media plus mastoiditis. Macewen also calls atten- 
tion to the fact that chronic suppuration of the middle ear extending 
over a period of two or more years is usually attended with necrosis. 
Neuralgic pains in the mastoid region occur in those cases attended with 
eburnizing osteosclerosis of the mastoid process. In cases in which 
acute exacerbations occur, there may be headache, especially at night. 
The mastoid skin may be slightly red, swollen, and hot, and the tern- 



772 THE EAR 

perature rises 1° or 2° above normal. The meatus is slightly swollen 
and hyperemia, and the postsuperior portion near the eardrum is tense 
and swollen or distinctly bulging. A cessation or diminution of the 
discharge is attended with pain, and signifies an obstruction to the 
discharge, the obstruction being due to acute swelling of the mucosa 
or to the formation of polypi. 

The progress of the disease varies greatly in different cases. In some 
it runs a long and uneventful course without distinct symptoms other 
than the intermittent discharge. In others, acute exacerbations occur 
every few weeks or months with the acute symptoms described under 
acute mastoiditis. In still others the discharge is so slight as to escape 
attention, unless the attic of the tympanum is explored with a probe. 
Any of these types may develop one or more of the labyrinthine or 
intracranial complications and become a very serious disease. 

Caries and necrosis of the mastoid ^process frequently follow the reten- 
tion of the purulent secretion. Most cases of two or more years' dura- 
tion are thus affected. Such destruction may take place without marked 
symptoms. The insidious progress of the disease makes it a formidable 
process. As Mace wen has so well said, one with a chronic otorrhea is 
likened unto one with a charge of dynamite in the head: he does not 
know when it will explode. Safety lies in removing the "charge" or 
diseased process. Tuberculous patients are especially subject to caries 
and necrosis, and do not heal so readily after operation. One of the 
author's cases on whom a radical operation was performed, could not 
be removed from the hospital for six weeks. Subsequently a secondary 
operation was performed, and it was again six weeks before it was pos- 
sible to remove her from the hospital. At the second operation, Thiersch 
grafts were applied, with success, the entire cavity being thus covered 
by epidermis. 

In caries and necrosis, careful examination will generally develop 
tenderness upon pressure, as the periosteum is apt to be swollen and 
inflamed. If in such cases the temperature is recorded every four hours, 
the record will show a typical septic curve. In cases attended with 
necrosis, paralysis of the facial nerve may be present. A bony seques- 
trum sometimes becomes separated and may be removed through the 
meatus. Goldstein reported a case in which the entire cochlea was 
exfoliated. 

Prognosis. — The prognosis varies with the focal centre of the disease, 
the extent of the necrosis, and the presence or absence of intracranial 
involvement. When there is free drainage and only the mucous mem- 
brane is involved, the disease is not essentially a serious one. When 
extensive necrosis and intracranial complications are present, the danger 
to life is imminent. Chronic sepsis, as evidenced by a yellow pasty skin 
and an increased leukocytosis, while not serious, undermines the general 
health and paves the way for the development of other serious diseases. 
According to T. Mark Hovell, attacks of partial or complete unconscious- 
ness, restlessness, and feverishness are always of grave import when 
occurring in a person suffering from disease of the mastoid process. 



CHRONIC MASTOIDITIS 773 

Treatment. — The local medical treatment of chronic mastoiditis is 
the same as that given for chronic suppurative otitis media. When this 
has been tried for a few weeks without effecting a cure, the mastoid 
antrum and cells and the middle ear may be opened. The object of 
this mode of treatment is to (a) establish free drainage, and (b) remove 
the morbid material, and establish the reaction of inflammation. 

General Indications for the Radical Mastoid Operation. — There are 
practically but three general types of mastoid operation now practised: 
one, the simple mastoid operation for acute mastoiditis, wherein only the 
mastoid antrum and cells are opened; another, the radical mastoid opera- 
tion for subacute and chronic mastoiditis, wherein the mastoid antrum 
and cells and the middle ear are thrown into one large irregular but freely 
communicating cavity; the other the meatomastoid operation, which may 
sometimes be used instead of the radical operation. The indications 
for the mastoid operations are in general those phenomena present in a 
persistent otorrhea which do not yield to local treatment (including 
the associated nasal and throat diseases) or which do not yield to opera- 
tions through the external auditory meatus. The more specific indica- 
tions are as follows: 

1. Persistent tenderness over the mastoid process, with or without 
copious ear discharge. 

2. Persistent ear discharge and polypi. 

3. Fistulous opening into the roof or postsuperior wall of the external 
auditory meatus. 

4. Caries of the attic, as shown by probing or by bone dust in the ear 
washings. 

5. Facial paralysis. 

6. Labyrinthine involvement, as shown by nystagmus, dizziness, 
nausea, staggering gait, and profound deafness. 

7. Chronic ear discharge with neuralgic pains over the mastoid process. 

8. Chronic ear discharge and septicemia. 

9. Intracranial complications and a history of chronic otorrhea. 
These and other signs may indicate the same type of mastoid operation. 

In view of the fact that life insurance companies refuse to insure persons 
affected with chronic otorrhea, the otorrhea alone may be a positive 
indication for the radical operation. 



CHAPTEE XLV 

PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS 
IN SUPPURATIVE OTITIS MEDIA 

There are four cardinal principles to be considered in the treat- 
ment of suppurative inflammations of the middle ear and mastoid cells, 
namely: (1) The promotion of the reaction of inflammation to aid Nature 
in combating The host of invading pathogenic microorganisms; (2) the 
establishment of free drainage and the reduction of pressure; (3) the 
removal of the morbid material; and (4) the maintenance of asepsis 
while repair is taking place. 

1. Promotion of the Reaction of Inflammation. — As shown in Chapter 
VI, on inflammation, the reaction of inflammation is a beneficent 
process, the object of which is to combat the infectious microorgan- 
isms. It is a threefold process, namely: (a) Increased hyperemia, 
(b) increased nutrition, and (c) increased leukocytosis in the affected 
tissues. 

The increased hyperemia floods the tissues with nutrition and thus 
raises their resistance. The increased migration of leukocytes into the 
tissues provides a fighting force which destroys the pathogenic bacteria 
and disposes of the dead cells of the tissues. As the reaction of inflam- 
mation is usually inadequate to successfully and quickly destroy the 
pathogenic bacteria, the therapeutic indications are to adopt measures 
which will increase or promote this reaction. Various modalities 
may be used for this purpose, some of which are, for anatomical and 
physiological reasons, especially well adapted to the treatment of the 
ear. (See Chapter VII, also Vaccine Therapy, at end of Chapter X.) 

As stated in Chapter VII, heat, irrigation with alkaline solutions, 
incisions, leeching, massage operations, and radiant energy may be used 
to promote the reaction of inflammation. 

Heat has long been used in the treatment of inflammation. Every- 
one has observed the increased redness of the skin under its influence. 
The hyperemia thus produced increases the nutrition, and it is now 
believed increases the migration of leukocytes into the tissues. 

There are differences in heat, as there are differences in silk and 
calico. Heat is produced by a wide range of vibrations. Some wave- 
lengths of wide amplitude and slow vibration produce heat of slight 
penetrating power. Other wave-lengths of short amplitude and rapid 
vibration produce heat of high penetrating power. The shorter the wave- 
length and the more rapid the vibrations the higher the penetrating 
power. Heat from a hot-water bag or low candle-power incandescent 
lamp is of long wave-length and slow vibration, and, therefore, of slight 
(774) 



SUPPURATIVE OTITIS MEDIA 775 

penetrating power. Heat from a 500 candle-power incandescent lamp 
is of short wave-length and rapid vibration, and is consequently of high 
penetrating power. The therapeutic value of heat is proportionate to its 
penetrating power. In selecting the modality for the application of heat 
these principles should be borne in mind. If the inflammation is super- 
ficial, a hot-water bottle or a low candle-power (16 to 100) lamp may be 
used, though a higher candle-power lamp will produce better results in 
a shorter time. If the inflammation is deep-seated, a high candle-power 
incandescent lamp (300 to 500 candle-power) or an arc light is indicated. 

Radiant light as given by the leukodescent lamp is a remedy of some 
value in suppurative otitis media. It not only gives off heat of high 
penetrating power, but it gives off rays possessing a high degree of 
chemical activity. The spectrum of the leukodescent lamp is rich in 
the blue violet rays which effect chemical changes in the tissues exposed 
to them. Such a lamp is, therefore, a mechanical device furnishing 
two powerful therapeutic agents — namely, heat with high penetrating 
power, and blue-violet rays of chemical activity. In the opinion of the 
author, however, the leukodescent light is not as good or as quick a 
remedy in acute suppurative otitis media as incision of the membrana 
tympani and leeching. The progress of the disease is so rapid, and the 
structures of such vital physiological importance, that it is imperative 
that immediate improvement be obtained. 

Incision of the inflamed tissue has long been a therapeutic measure 
of acknowledged efficacy. In the treatment of acute catarrhal and the 
pre-perforative stage of suppurative otitis media, incision of the mem- 
brana tympani is one of the most efficient modes of treatment. The good 
effects following such an incision are not altogether due to the increased 
hyperemia and leukocytosis, though this influence is greater than is 
generally believed. In addition to the increased reaction of inflamma- 
tion, the incision establishes free drainage, relieves the pressure, and 
favors the removal of the morbid material. 

Incision of the membrana tympani is an almost ideal therapeutic 
measure in the early or pre-perforative stage of acute suppurative otitis 
media, though it is of little value in the later stages of the disease, and 
in the chronic type. Little can be done by promoting the reaction of 
inflammation in chronic suppurative otitis media. In such cases the 
establishment of free drainage and the total removal of the morbid 
material should be accomplished. In acute cases, the incision of the 
membrana tympani should be long and curved, or V-shaped, to permit 
the secretions to flow through it. 

Leeching is another old and all but discarded remedy in the treatment 
of acute inflammation. In the author's hands it has proved one of the 
most satisfactory methods of combating acute catarrhal and suppurative 
otitis media. It is best to apply from three to five leeches over the mastoid 
process and one to the tragus in front of the ear. If applied in the 
pre-perforative stage, or when the mastoid is swollen and tender, or 
when pain is present, the improvement is usually prompt, the case often 
proceeding toward rapid resolution. 



776 THE EAR 

Leeching increases the hyperemia and the migration of leukocytes 
into the inflamed tissues, and thus favors the destruction of the patho- 
genic bacteria and the repair of the tissues. 

Artificial leeching is, perhaps, of equal value, and is easier of applica- 
tion. The skin over the mastoid process should be incised, as shown 
in Fig. 408, the circular knife being adjusted with a set screw so as to 
cut the desired depth. When the incision is made the exhaust pump 
should be applied, as shown in Fig. 409, and the air exhausted by turning 
the hand screw. An ounce of blood may thus be drawn from the in- 
flamed tissues. The effect of this procedure is to overcome the venous 
stasis and edema, thus establishing a more rapid arterial flow of blood 
through the tissues. The nutrition of the tissues is raised and the 
migration of leukocytes increased. 

Massage is of little value in promoting the reaction of inflammation in 
otitis media. In tubal catarrh, however, external mechanical vibratory 
massage under the angle of the jaw over the course of the Eustachian 
tube will often quickly relieve the edematous obstruction to this tube. 

Vaccine and Leukocyte Extract Therapy. — 1. Endotoxin is a toxic 
substance elaborated within the pathogenic bacteria at the time of 
their dissolution or death. Each type of germ produces its own peculiar 
endotoxin. 

2. Each class of bacteria gives rise to antibodies peculiar to its 
class, and the antibodies counteract the endotoxins. 

3. Pathogenic bacteria cause pathologic processes by (a) the irrita- 
tion produced by the presence of the bacteria in the tissues and (b) by 
the presence of the endotoxin in the circulating blood. 

The irritation produced by the presence of the pathogenic bacteria 
in the tissues, and of endotoxin in the blood is counteracted by (a) the 
antibodies given being by the parent pathogenic bacteria, (b) by the 
phagocytes, a type of blood corpuscle which actually destroys bacteria. 
Phagocytes are normally present in the blood, and, in the presence of 
infection, they are concentrated at the area of infection, and are greatly 
increased throughout the blood currents. Under ordinary conditions 
of infection, the increase in white blood corpuscles corresponds to the 
increase in the bacterial development. This is especially true in refer- 
ence to the increase in the polymorphonuclear cells. If the bacterial 
increase remains long in excess of the white blood corpuscle increase, 
the corpuscle-producing organism becomes exhausted, and we have 
the clinical phenomenon of an increasing sepsis with a diminishing 
number of polymorphonuclear cells, (c) The destruction of the bac- 
teria is also aided by the opsonins which are normally in the blood. 
They act by reducing the vitality of the pathogenic microorganisms, 
thereby rendering them easy preys to the phagocytes. 

Recapitulation. — 1. Under normal conditions of health, pathogenic 
bacteria are present in the body in more or less quantities and morbid 
processes are prevented by the (a) phagocytes, more particularly the 
polymorphonuclear cells), the (b) opsonins aiding the phagocytes 
by reducing the resistance of the bacteria, and (c) the antibodies given 



SUPPURATIVE OTITIS MEDIA 111 

being by the presence of the pathogenic bacteria counteracting the 
poisonous effects of the endotoxins liberated in the blood stream at 
the death or dissolution of the pathogenic microorganisms. The 
pathogenic bacteria are usually produced at more or less regular 
intervals, swarm, so to speak, so that there are periods of bacterial 
activity followed by periods of bacterial death. During the periods 
of bacterial activity the phagocytes and opsonins are especially active, 
in the destruction of the bacteria, and the antibodies are especially 
active in counteracting the endotoxin liberated in the blood streams. 
Another feature not always considered in infective processes is, that 
the amount of blood is increased in the infected organ or tissues. This 
is of clinical importance because it means that an increased food supply 
is given to the histologic cells of the tissues during the term of stress 
placed upon them by the pathogenic bacteria and endotoxin. Should 
the pathogenic bacteria for any reason increase out of proportion to 
the phagocytes, antibodies, and blood (food) supply, we have the 
clinical phenomenon of increasing sepsis, and a diminishing polymor- 
phonuclear count. A histologic cell soldiery, succumbing to an over- 
powering invading pathogenic bacteria host. 

Autogenous Vaccines. — An autogenous vaccine is a preparation 
of dead bacteria held in suspension in normal salt solution. A culture 
is made from the pus of the infected area, the bacteria responsible 
for the pathologic process isolated, and submitted to a temperature 
of 60° C. for forty-five minutes. According to Dr. Nagel, of Boston, 
if the bacteria are overheated the vaccine loses some of its thera- 
peutic qualities, a fact which may account for many of the failures 
attending its use. 

Other factors also influence the success or failure of autogenous 
vaccines in the treatment of infections. Of these we may mention 
the drain upon the vital forces, attending the administration of a 
vaccine. If the patient is in a relatively good condition, i. e., if his 
vital forces are not depleted, the use of vaccine may be followed by 
good results. If, on the contrary, his vital forces are at a low ebb, the 
vaccine will reduce them so much lower that he can not bridge over 
the depression gap, and he gravitates to a still lower plane of resistance, 
and the infection and sepsis become more and more pronounced. 
These facts may throw light upon the relative failure of vaccines in 
acute infections, and in cases in which there is great debility and 
profound sepsis, hence the added stress attending the injection of the 
vaccine is followed by evil results. If, on the contrary, the disease is 
pursuing a subacute or chronic course, and the vital forces are strong, 
the depression gap produced by the vaccine is bridged over and the 
antibodies are produced in quantities sufficient to neutralize the specific 
microorganisms and their endotoxin. 

Vaccines are, therefore, of greater value in subacute and chronic 
infectious processes. In my experience they have been of special 
value following operations upon chronic nasal sinus, and aural disease. 
I have also had good results following operation upon pachymenin- 



778 THE EAR 

gitis. From one to two weeks should elapse after the operation before 
the vaccine is administered, as the stress attending the administration 
of the vaccine should not be added to that attending the operation. 
When the surgical shock has subsided, and the vital forces have been 
renewed the vaccine may be given with advantage. 

Another factor of great clinical significance is that each type of 
pathogenic bacteria (streptococcus, staphylococcus, pneumococcus, 
etc.) produces antibodies peculiar to itself, and which are corrective 
only to its kind. Hence, the antibodies liberated in the blood by the 
staphylococcus vaccine would exert no corrective influence upon 
streptococci or pneumococci, whereas it would exert a favorable or 
restraining influence upon staphylococci. There are various strains 
of streptococci, staphylococci, etc., each possessing a virulency peculiar 
to itself, and arousing strains of antibodies, which exert a restraining 
influence only upon the peculiar strain of cocci giving it birth. It is, 
apparent, therefore, that the best results can only be obtained by 
using vaccines made from the germs obtained from the diseased area 
of each patient. In other words, only autogenous vaccines should 
be used. 

The injections should be given in increasing doses every three or 
four days, and as soon as reaction symptoms such as a feeling of exhaus- 
tion, etc., are noticed, the injections should be stopped for a week or 
two, or until the vital forces have been reestablished. 

Stock Vaccines. — Stock vaccines are usually prepared by the various 
pharmaceutical houses from the various pathogenic microorganisms, 
as streptococci, staphylococci, pneumococci, etc. However well they 
may be prepared, they do not meet the therapeutic indications as 
well as the autogenous vaccines, as they (stock vaccines) do not give 
being to antibodies exactly suited to counteract the specific bacteria 
and endotoxin present. In addition to the foregoing objections the 
stock vaccines more or less deplete the vital forces without giving 
any beneficial results in return, as is done when an autogenous vaccine 
is administered. 

The Leukocyte Extract of Hiss. — Conceive the soldier's combative 
outfit to consist of food, a rifle, cartridges, and a saber. During times 
of peace he makes but little use of his accoutrement. In war he not 
only uses his armament, but he needs and receives renewals of the same, 
as the exigencies of the occasion require. Conceive the leukocyte to 
be a soldier guarding the frontiers of the system against an invading 
host of pathogenic bacteria. In times of health it has potentialities 
within itself to maintain the balance of power. In times of stress 
it may or may not have enough potentialities within itself to restrain 
or destroy the invading host. It needs more food, rifles, and cartridges 
than the organism can supply. Hiss has attempted to meet this emer- 
gency by making an extract containing the essential properties of 
the leukocytes. That is, the extract contains the elements necessary 
to combat the bacteria and endotoxin, and its administration does 
not use any of the vital forces for their production, as in the adminis- 



SUPPURATIVE OTITIS MEDIA 779 

tering of autogenous or stock vaccines. The Hiss leukocyte extract 
seems to be food and artillery combined. The extract is readily dif- 
fusible through the system when injected into the subcutaneous tissue. 
It is especially indicated in (a) acute infectious processes in which the 
autogenous vaccines are contraindicated. It is also indicated (h) in 
those cases in which profound sepsis and depression of vital forces 
are present. In such cases there is an increasing sepsis, and a dimin- 
ishing leukocyte count and diminishing polymorphonuclear percentage. 
While the exact status of either the vaccine or leukocyte extract 
is not yet established, each has a field of usefulness of no mean pro- 
portions. Vaccine and leukocyte therapy are distinct steps in the 
right direction, even though we do not as yet know the ultimate goal 
to which they lead. 

2. Establishing Free Drainage. — The second principle of treatment, the 
establishment of free drainage, is a very important part of the treatment 
of suppurative otitis media. If free drainage is maintained, pressure 
necrosis is not apt to occur; indeed, if present, it may disappear. 

In the early stage of acute otitis media free drainage may be established 
by incising the membrana tympani, the Eustachian tube being, for the 
time, inadequate to carry away the excess of secretions. A free incision 
of the membrana tympani affords an accessory outlet for the secretions, 
and, in addition, it promotes the reaction of inflammation and relieves 
the pressure and attending necrosis. 

If the obstruction is in the aditus ad antrum, incision of the membrana 
tympani may fail to establish free drainage, in which case it may be 
necessary to perform a mastoid operation. In some cases of chronic 
otorrhea, the obstruction is due to the heads of the malleus and incus, 
together with the ligamentous bands and adventitious cicatricial tissue 
resulting from the inflammatory process. In such cases the removal of 
the malleus and incus establish free drainage. Heath claims that 
the Eustachian tube is usually adequate to drain the tympanic cavity, 
even when diseased, but that it is inadequate to also drain the diseased 
mastoid antrum and cells. He therefore recommends that the secretions 
from the antrum and mastoid cells be diverted from the aditus ad antrum 
to the external auditory meatus, as described in the meatomastcid 
operation. 

3. Removal of Morbid Material. — Whatever method of treatment is 
adopted, earnest effort should be made to remove all obstruction to the 
flow of secretions from the tympanic cavity. In infants and children the 
removal of the adenoids may accomplish the purpose by unblocking 
the Eustachian tubes. The removal of aural polypi or granulations 
may temporarily establish drainage. Incision of the membrana tympani, 
leeching, hot irrigations, dry heat, etc., may act favorably, but in many 
cases it will be necessary to resort to a mastoid operation. In simple 
cases the morbid material consists of the purulent secretions, which are 
successfully removed by drainage. In the more complicated cases, in 
which granulations and necrosed bone are present, an operation may be 
required to accomplish the result. 



780 



THE EAR 



To remove the granulations, it may be necessary to enlarge the perfora- 
tion in the drumhead by radiating incisions. Through this opening 
the granulations can be still further examined and removed, either 
with a snare (Fig. 419) or with a small spoon curette. Local anesthesia 
may be induced with cocaine (10 to 20 per cent.), or with the following 
mixture : 



1$. — Cocaine crystals, 

Carbolic acid crystals, 

Menthol crystals 

Mix by rubbing in a mortar, and a syrupy fluid is formed. 



aa, 3j — M. 



The above solution, when dropped into the meatus, will produce local 
anesthesia when cocaine fails to do so. 

If the obstruction is in the aditus, the problem becomes at once more 
difficult and serious. It is practically impossible to reach the canal 



Fig. 419 




Showing the removal of an aural polyp which projects into the meatus through a perforation in 

the membrana tympani. 

through the external auditory meatus without resorting to a mastoid 
operation. Sometimes, if the malleus and incus are removed, the obstruc- 
tion will gradually disappear without the mastoid operation. The 
advantage to be gained by the operation is that the disintegration which 
occurs with such rapidity under retention pressure is checked before 
serious and extended destruction of the tissue takes place, and the danger 
of meningeal and cranial involvement is thereby reduced to the minimum. 
If the fain is associated with bulging and redness of the postsuperior 
wall of the meatus near the drumhead, the indications for immediate 
operation are imperative. If the bulging and redness are not present, 
other treatment may be tried. In the meantime, close observation of 
the case should be maintained. A rapid rise in temperature, with chills 
or chilliness and profuse sweating, strongly indicate septic poisoning, 
possibly from sinus thrombosis. 



SUPPURATIVE OTITIS MEDIA AND MASTOIDITIS 781 

4. Maintaining Asepsis. — Having promoted the reaction of inflamma- 
tion, established free drainage, removed the pressure and the morbid 
material from the diseased ear or mastoid cells, there remains but little 
to do to maintain the parts surgically clean. Loose gauze dressings 
applied to the auditory meatus or to the mastoid wound is all that is 
necessary for this purpose. Extraneous infection is thus prevented 
while the reparative process is in progress. 



TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA AND 

MASTOIDITIS 

The consideration of this subject will not be divided into medical 
and surgical treatment, as is usually done, but will be considered accord- 
ing to the predominance of the type and location of the morbid process. 

Suppuration of the atrium (lower chamber of the middle ear), perhaps, 
does not exist alone, there being usually associated with it the same type 
of inflammation in the attic, antrum, and mastoid cells. The focal centre 
of the process may, however, be located in the atrium, and the case may 
be successfully treated via the auditory meatus. 

The dry gauze treatment (e. g., a strip of sterile gauze loosely packed 
in the meatus) should be faithfully practised for several weeks. In 
chronic cases the perforation in the drumhead is usually quite large, 
sometimes involving the entire membrane. When such is the case, it is 
not necessary to enlarge the perforation or incise the drumhead. The 
gauze wick should be introduced into the cavity of the middle ear, and 
the meatus loosely packed. It is usually sufficient to apply the gauze 
every alternate day, although it may be necessary to do it oftener. 

Alcohol Treatment. — This treatment should be preceded by a thorough 
cleansing of the secretions from the meatus with cotton- wound applicators 
and inflating the middle ear. 

The alcohol should vary in strength (25 to 95 per cent.) according to 
the pain produced by its introduction, and should be left in the middle 
ear for from five to twenty minutes, the patient inclining the head to one 
side. Some cases tolerate the 95 per cent, solution from the start, while 
others will complain of pain if a greater strength than 25 per cent, is 
used. In such cases, begin with the weaker solution, and then instil 
a stronger until the full strength solutions are used. 

In the interims between treatments the ear may be left without special 
protection other than a loose piece of sterile gauze in the external meatus. 

The treatments may be repeated on alternate days, or as often as 
indicated. 

Some writers advocate the addition of boric acid to the alcohol, while 
others use an etheric-alcohol solution of iodoform. 

Alcohol acts as a hygroscopic agent, which depletes the edematous 
membrane and granulation tissue. It is an antiseptic and astringent, 
and excites the reaction of inflammation. 



782 THE EAR 

The Compound Tincture of Benzoin. — During the last ten years the 
author has used the compound tincture of benzoin in nearly every case of 
otorrhea treated, with great satisfaction. Its efficacy is in part due to the 
alcohol in its composition, but not altogether. It is more soothing than 
plain alcohol, more antiseptic, and more healing. It has proved to be of 
special value in those cases in which the fetid odor is present. This 
speedily disappears and the other features of the case also improve. 

The compound tincture of benzoin should be dropped into the meatus, 
the head being inclined toward the opposite side. After such a treatment, 
if the discharge is not too profuse, the gauze may be allowed to remain 
in the ear and meatus for two or three days without developing fetor. 

The middle ear should be previously cleansed as described above, but 
after a few applications of the remedy it may be abandoned, as the 
discharge often rapidly decreases until there is scarcely a drop on the 
gauze when removed. 

It is not to be inferred from what has been said that the otorrhea will 
not return after the discontinuance of the benzoin, for it is very apt to do 
so in most cases, no matter what form of local treatment is pursued. 

Irrigation. — The use of the syringe is not indicated, as it is in acute 
cases. It may be used to advantage, however, when there is a consider- 
able accumulation of desiccated or tenacious mucus and pus in the 
atrium of the middle ear. The force of the stream loosens and propels 
the secretions from the middle ear, and thus prepares the tissues for 
treatment by other methods. Sterile water or normal salt solution 
should be used as hot as can be comfortably borne by the patient, one- 
half gallon being the correct amount for each treatment. 

Boric Acid Powder Treatment. — This method of treatment is of less 
value in chronic than in acute inflammations of the middle ear. If the 
discharge is profuse, it may be used, although other measures afford 
more relief. If used, the powder should be blown, not poured, into the 
meatus. 

Camphoroxol has recently been highly recommended by Hotz and 
others in obstinate otorrhea in which other methods of treatment had 
failed. Hotz reports several cases in which the remedy seemed to 
give speedy and satisfactory relief. He injects it into the middle ear 
through the Eustachian tube by means of the Weber-Liel catheter. 
Further observations along this line are needed, however, before the 
real value of this remedy can be estimated. 

TREATMENT OF SUPPURATION INVOLVING THE ATRIUM 

AND ATTIC 

Under this caption are included those cases in which the attic is chiefly 
involved, and in which this centre forms the chief source of annoyance 
and danger. The consideration of the best methods of treatment will 
therefore hinge upon the structure and arrangement of the parts com- 
posing the attic. 



SUPPURATIVE OTITIS MEDIA AND MASTOIDITIS 783 

The point of chief interest is the lower boundary or floor of the attic, 
namely, the heads of the malleus and incus, and the ligaments and ad- 
ventitious fibrous bands uniting them to the walls of the tympanum. 
Another point of clinical interest is ShrapnelFs membrane, or the mem- 
brana flaccida. Perforation of this membrane affords one of the most 
obvious signs of attic suppuration. Irrigation of the attic may be ac- 
complished with a curved cannula inserted through the perforation in 
ShrapnelFs membrane, and local medication and explorations may be 
carried on through it. 

The floor of the attic is of importance because, whereas in health it 
affords ample drainage for the secretions, it is oftentimes inadequate 
in chronic otorrhea. The inadequacy may be due to the excessive and 
heavy secretions, or to a more or less complete obstruction by the adven- 
titious fibrous tissue of the spaces in the floor of the attic. Either condi- 
tion will cause the secretions to remain in the attic, which may give rise 
to serious pathological changes, as necrosis and septicemia. 

While the principles of treatment remain the same, the motive for 
treatment increases tenfold. 

Free drainage is imperative and should be established by surgical 
interference. This may be facilitated by enlarging the perforation in 
ShrapnelFs membrane by an incision extending anteriorly and pos- 
teriorly. The treatment should be addressed not alone to the attic, 
but to the atrium also. In other words, the treatment described in the 
preceding section should be used, and in addition thereto the following 
measures should be instituted: 

The attic should be kept as free of secretions as possible by applying 
suction to the external auditory meatus with Siegle's otoscope or Del- 
stanche's rarefacteur. The spaces of the attic should be irrigated through 
the perforation in ShrapnelFs membrane, and a 2 to 4 per cent, solution 
of the nitrate of silver applied with delicate cotton-wound applicators. 
Should these measures fail, the radical mastoid operation may be 
performed, special care being taken to remove the external wall of the 
attic (roof of the meatus near the drumhead). By so doing the attic is 
fully exposed in the after-treatment. 



CHAPTEE XLVI 

GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 

Microorganisms are the exciting causes of middle- ear and intra- 
cranial pyogenic processes. Various organisms are active, either alone 
or in combination, no special one being characteristic of these processes. 

The free communication between the epipharynx and the middle ear, 
and the perforated drumhead makes infection easy if the local conditions 
are favorable. Such a condition presents itself during the course of 
one of the exanthematous fevers when the vitality is lowered. Patho- 
logical changes occur in the mucosa, microorganisms continue to flourish, 
and the suppurative process is established. The cilia which normally 
partially cover the tympanic mucosa are destroyed, or their vitality is so 
impaired that their propelling function is no longer adequate to drive 
the secretions toward the Eustachian outlet. Accumulation, decompo- 
sition, and irritation follow. The mucosa breaks down, the periosteum 
covering the bone loses its vitality and disintegrates, and the bone 
depending upon it for nutrition becomes carious. The arteries in the 
mucosa become thrombosed, and the arterial supply is thus cut off 
from the membrane and periosteum as well as from the bone. Thus, 
the process of disintegration proceeds with greater or less activity, often- 
times without serious symptoms being present. The brain may be 
exposed by the caries of the tegmen tympani and antri, or through 
various other channels of communication. 

It has been said that about two years of chronic suppuration usually 
precedes bone necrosis in the middle ear and its accessory cavities. This 
should be taken only as an approximate estimate, as the time varies with 
the type of the infection, and with the obstruction offered to the discharge 
of the morbid secretions. If the flow from the mastoid cells and antrum 
is free and unobstructed, the process may continue for years without 
bony necrosis. If, on the other hand, marked obstruction occurs early 
in the suppurative process, bone necrosis may take place before 
the two years have elapsed. This is often the case in acute primary 
mastoiditis. 

It is of great importance in estimating the gravity of a suppurative 
process in the tympanum to determine definitely the predominant char- 
acter of the microbic infection present. To this end cultures and 
microscopic examinations should be made. While but few physicians 
are prepared to make either the cultures or microscopic examinations, 
nearly all know where they can secure culture tubes and have such 
examinations made. The attending surgeon should smear the secre- 
tion from the ear on the contents of the culture tube and send it to a 
pathologist. 
(784) 



GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 785 

A few places where the above examinations may be made are: 

(a) The Health Board of the physician's own city or some neighbor- 
ing city. 

(b) A neighboring physician. 

(c) The nearest medical college, or the one from which the physician 
graduated. 

(d) A pathological laboratory established for the purpose of accom- 
modating those in need of such work. 

The expense of such an examination is small, and the information 
obtained may be of inestimable value to the patient. 

John Funke has reported the results of his observations as to the 
"Bacteriology of Otitis Media," and his work seems so conclusive and 
suggestive that an epitome of it is herewith given : 

The following conclusions are based on a study of the literature of 
otitis media and his observations: 

1. There is no specific organism of otitis media. 

2. Acute otitis media is not invariably monomicrobic, as is com- 
monly held. The pathogenic organism present may be of a single 
variety, but with it are frequently found a varying number of associated 
bacteria, which may or may not be influential in determining the outcome 
of the case. 

3. The organisms commonly found, in the order of frequency, are: 
The pneumococcus, streptococcus, pyogenic staphylococci (albus and 
aureus), and the bacillus of Friedlander. He is strongly inclined toward 
the belief in a definite grippal otitis, primarily due to the influenza bacil- 
lus, which, however, becomes quickly associated with, or replaced by, 
other organisms. 

4. The Bacillus diphtherias is more commonly present in otorrhea 
than is usually believed; it may be (a) the initial infecting agent, or (b) 
it may enter with the streptococcus or pneumococcus, or (c) it may be a 
secondary infection carried to the already infected ear by the fingers of 
the patient, or otherwise, as held by Babinski. 

5. It is reasonable to believe, as Funke' s observations show, that it 
persists for a varying period of time in the discharges, and may consti- 
tute a centre of danger, j ust as has been thoroughly established concern- 
ing its prolonged residence in the nasal cavities, pharynx, etc. Its 
frequent association with the Bacillus pseudodiphtheriee has here the 
same significance as elsewhere, a factor not as yet fully determined. 

6. The streptococcal h fections are more grave and persist longer 
than pure pneumococcal infections, but both are usually supplanted by 
the staphylococcal sooner or later. 

7. There is a true pneumobacillary otitis, usually acute and quickly 
converted into a mixed infection. The gravity of the process depends 
almost exclusively upon the character of the mixed or secondary infection. 

8. Chronic suppurative otitis media is practically always a sequence 
of the acute. 

9. Like the acute, it possesses no specific organisms. 

10. Unlike the acute, it is almost always polymicrobic. 

50 



786 THE EAR 

11. Its polymicrobic character may be evinced in any of three ways: 
(a) A mixed infection of pathogenic organisms; (b) one or more recog- 
nized pathogenic organisms (usually pyogenic staphylococci), with 
one or more bacteria usually regarded as saprophytes; (c) the usual 
pyogenic and pathogenic bacteria are absent, and the discharges are 
maintained through the activity of organisms that commonly lead a 
saprophytic existence. 

12. While anaerobic organisms may play an important part in the 
pathogenesis of chronic suppurative otitis media, Funke's observations 
have not established their almost constant presence, as maintained by 
Rist. 

13. The fetor met in the cases reported here can be explained by 
the presence of Bacillus pyogenes fcetidus without anaerobic organisms. 

14. All clinical and collated bacteriological data indicate that otitic 
inflammations present different bacteriological findings in different 
localities. According to Moos, during the influenza epidemic of 1890 
in Vienna, the otitic complications were due to the pneumococcus 
( Weichselbaum) and to the streptococcus in Strasburg, Griefswald, 
and Bonn (Ribbert). 

15. Reports gathered from literature establish the existence of a 
primary tuberculous otitis, but all observers are of one mind as to the 
almost utter impossibility of the routine demonstration of the bacillus in 
discharge. 

16. For the demonstration of the tubercle bacillus in suspected 
cases, Funke recommends an examination of tissue obtained by the 
curette. 

Middle-ear Suppuration. — Microscopic Examination of One Hundred 
Cases, with Special Reference to the Presence of Tubercle Bacilli and Acid- 
fast Bacilli. — Wyatt Wingrave 1 gives the following analysis: Special care 
was taken in obtaining the discharge. Carbol-fuchsin was used in 
staining, with methylene blue as a counterstain: 



Squamous and pus cells present together in 41 

Pus alone 38 

Squamous alone .21 

Bacteria. 

Staphylococci 

Diplococci 

Streptococci 

Bacillus proteus vulgaris 

Micrococcus tetragenus .... 

Bacillus coli 

33 
Gonococci 

Bacillus subtilis ° 

Aspergillus niger 

Leptothrix 

Diphtheria (Klebs-Loeffler) ' *■ 

Yeast 1 

'Jour. Laryngol., Rhin,, and Otol., March, 1903. 



GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 787 

Gradle and others, some years ago, called attention to the odor attend- 
ing chronic otorrhea, claiming its presence or absence was the "most 
sensitive criterion of the efficacy of the treatment." 

So long as the pus of the otorrhea smells fetid, the treatment em- 
ployed has exerted no curative influence on the disease; and, conversely, 
"the first sign from any treatment of curative influence is its effect 
upon the odor of the discharges " (Gradle). 

Macewen says: "The virulence of a discharge cannot be measured by 
its odor. Nearly odorless otorrhea may contain pathogenic micrococci, 
and some of the most serious intracranial inflammatory lesions ensue 
in the presence of odorless otitis media. It is well, therefore, in esti- 
mating the gravity of an otorrhea that pus from the middle ear should 
be stained and examined microscopically and by cultivations." 

He states, further, that intracranial complications often arise in the 
course of fetid otorrhea, but that the pathogenic germ is not the one 
causing the odor, it usually being a non-pathogenic microorganism. 

These views, while they seem to be diametrically opposed to each 
other, are really not so opposite as they appear. The first is fallacious, 
in that it leads to the inference that with the disappearance of the odor 
the patient's condition becomes safe; whereas, the second view tells us 
the absence of fetor is no criterion as to the non-virulence of the infection. 
Gradle' s views lead, by inference, to the conclusion that absence of fetor 
is a guide to the mildness of the infection; whereas, Macewen says the 
absence of fetor gives no information whatever as to the virulence of 
the infection. He goes still farther and says some of the most virulent 
intracranial infections have occurred in connection with odorless 
otorrhea. 

The author is inclined to agree with Macewen on this point, although 
he readily admits Gradle's major proposition, that the disappearance of 
the odor under the syringe, etc., usually heralds an improved drainage 
and ventilation. The improvement, however, is not due to the removal 
of the odor or the germs producing it, but to the removal of the sapro- 
phytic bacteria and the establishment of free drainage by the removal of 
the desiccated secretions. The disappearance of the odor is incidental, 
and signifies that other and more virulent organisms may have been 
removed also. 

When the true nature of chronic otorrhea is explained to patients, 
many of them reply that they have had the discharge off and on for many 
years with no untoward result, and that they do not fear serious compli- 
cations in the future. They express a belief that is often too prevalent 
among physicians, namely, that chronicity of otorrhea is a guarantee of 
its innocent nature. The process of disintegration has been going on, 
and may continue to do so as long as the otorrhea lasts. Fresh in- 
vasions of germs, or the encroachment upon a new area, or a lowered 
vitality of the patient, may give rise to sudden and alarming symptoms. 

It may be said that the more chronic the otorrhea the greater the danger 
of intracranial or other extension of the infective process. 

Acute primary otitis media suppurativa rarely extends to the brain or 



788 THE EAR 

meninges, as the process does not continue long enough to break down 
the mucous membrane, bone, and other tissues enveloping it. 

In infants this protection is not so complete, as the various parts of 
the temporal bone are not yet united by ossification. The vascular and 
cartilaginous lines of union afford less resistance to the transmission of 
microorganisms to the cranial cavity; hence, intracranial involvement is 
more common in infants in the course of, or subsequent to, an acute 
primary suppurative otitis media. 

In addition to the infection and consequent ulceration, thrombosis, 
and necrosis, there are other pathological conditions which are inci- 
dental to the suppurative process. Adhesive bands often form in the 
course of this disease, and the ossicles become bound to each other and 
to the tympanic walls. The handle of the malleus is retracted and may 
become adherent to the promontory. 

The writer has a case under observation, aged forty years, with adhe- 
sion of the handle of the malleus to the promontory. When a young 
child she had suppuration of the middle ear, following scarlet fever. 
There have been occasional discharges since then. When she came 
under observation there was a perforation of Shrapnett's membrane. 
This healed under applications of the nitrate of silver. Examination 
with Siegle's otoscope shows the malleus to be adherent to the promon- 
tory. The anterior half of the drumhead is also adherent in places, 
while the posterior half is perfectly free. In other cases the adhesions 
have been severed with great improvement of the hearing. 

Calcareous salts may be deposited in the drumhead and in the tympanic 
mucosa. The articulations of the ossicles may become ankylosed. The 
foot plate of the stapes is sometimes ankylosed from the deposit of lime 
salts in the fibrous ring which unites it to the margin of the oval window 
(fenestra of vestibule). This condition may be mistaken for hyperostosis 
of the bony capsule of the labyrinth (spongifying), though in the latter 
condition the drumhead and Eustachian tube are normal. 

Granulations (aural polypi) are common, especially in old cases, in 
which the mucosa and periosteum are ulcerated and bone necrosis is 
present. They are the expression of Nature's effort to repair the tissues. 



CHAPTEK XLVII 

INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF 
OTITIC ORIGIN 

General Considerations. — Infection and inflammation of the middle 
ear, mastoid cells, and labyrinth are not, per se, usually a serious menace 
to life. The real danger is in the extension of the infection to the con- 
tents of the cranium or to the jugular vein, and thence to the important 
viscera, as the lungs, spleen, liver, heart, and kidneys, or a general 
dissemination throughout the body (general septicemia). Pneumonia, 
splenitis, hepatitis, endocarditis, and nephritis of otitic origin have been 
observed. The infection more often extends to the intracranial sinuses 
(veins) and to the jugular vein. 

Of the intracranial pyogenic infections, thrombosis of the sigmoid 
portion of the lateral sinus, and the various types of meningitis, are most 
often observed. As the symptoms are not always characteristic of the 
type and field of invasion, the differential diagnosis is often difficult to 
make. There are, however, certain general characteristic phenomena, 
especially after the process is well advanced, which usually enable the 
aural surgeon to diagnosticate the condition present. When, for example, 
there is a chill, followed by a rapid and excessive rise of temperature, 
the evidence is conclusive that the system has been invaded by a nu- 
merous pyogenic host from some source. The most probable source of 
such an invasion is a disintegrating thrombus. The thrombus, being 
infected, finally undergoes disintegration, and the pathogenic bacteria 
are thrown in great numbers into the general circulation. As the sig- 
moid portion of the lateral sinus is in intimate anatomical relation to 
the mastoid process, the natural inference to be drawn from the chill 
and rapid rise of temperature is that sigmoid sinus thrombosis is pres- 
ent. If after the lapse of twenty-four hours a similar symptom com- 
plex recurs, the diagnosis may be more surely made. The thrombus 
may, however, be either the lateral, the superior, or inferior petrosal, 
longitudinal, or the cavernous sinus. These sinuses are, however, 
usually involved secondarily to the sigmoid sinus. The symptoms of 
cavernous thrombosis are so characteristic that, when involved, the 
diagnosis is easy. 

Diffused purulent meningitis also presents certain characteristic 
symptoms which render the diagnosis comparatively easy. The tem- 
perature remains more or less constantly elevated, whereas in thrombosis 
there are distinct chills followed by a sudden and marked rise in the 
temperature, and a recession to nearly normal within from six to ten 
hours. Extradural abscess and brain abscess may be attended with a 

(789) 



790 THE EAR 

moderate elevation of temperature or none at all, though there are fre- 
quent exceptions to this rule. 

Lumbar Puncture.— Lumbar puncture for the diagnosis of menin- 
gitis should be made between the third and fourth lumbar vertebrae. 
A tapeline or cord passing around the body on a level with the crest 
of the ilia passes over the spine of the fourth lumbar vertebra; the spine 
just above is the third lumbar vertebra, and at a point midway between 
the two spines is the location for making the puncture. The needle 
should be introduced at a point a little to one side of the median line, 
and should be five or six inches long and 1 mm. in diameter. The 
spinal fluid will escape spontaneously when the point of the needle 
reaches the space in the cord. The increased tension may be estimated 
by the force and rapidity with which the fluid escapes. If normal, it 
drips rather freely from the needle, whereas in meningitis it escapes 
more rapidly. In some cases, however, the tension is not much elevated. 

In infants and young children a simple acute otitis media may give rise 
to symptoms simulating cerebral complications, as headache, nausea, 
vomiting, and excessive elevation of temperature (Gradle). If menin- 
gitis is suspected, the diagnosis may be cleared by making a lumbar 
puncture and subjecting the removed spinal fluid to microscopic examina- 
tion. If purulent meningitis is present, the fluid is turbid and loaded 
with pus cells and pathogenic bacteria, especially streptococci. If 
the fluid escapes under high pressure, and is clear and contains only 
a few leukocytes and no demonstrable bacteria, serous meningitis is 
present, and a mastoid operation should effect a cure without resorting 
to an exposure of the cranial contents other than at the atrium of infec- 
tion, the tegmen tympani or antri. Lumbar puncture is negative in 
reference to the other intracranial infections. 

These and other clinical phenomena usually enable the aural surgeon 
to differentiate the various extensions of the infection from the ear and 
mastoid cells to the cranial cavity. In the following presentation to 
the intracranial and jugular infections only the more typical clinical 
phenomena will be given. 



MENINGITIS SEROSA 

This disease is of otitic origin and is characterized by a serous infiltra- 
tion of the pia mater and an increase in the cerebrospinal fluicl in the 
subarachnoid space and in the ventricles of the brain. 

Etiology. — (a) It is more often a complication of chronic otitis media 
and mastoiditis, (b) The channels of invasion may be through the 
tegmen tympani and antri, or through the labyrinth. 

Symptoms. — Headache, dizziness, nystagmus, nausea, vomiting, 
restlessness, ataxia, torticollis, disturbances of vision, etc., may be 
present, though not all of them at one time. The symptoms are not 
different from those in the suppurative form of meningitis, and it is, 
therefore, difficult to make a diagnosis before operation. If there is 



MENINGITIS SEROSA 791 

a spontaneous cessation of the meningeal symptoms, or if they cease 
after a mastoid operation, the disease is probably serous in character, 
the purulent forms rarely being thus favorably affected. Lumbar 
puncture is negative. 

There are two chief differential points between diffuse suppurative 
meningitis (leptomeningitis) and serous meningitis, namely: (1) in 
suppurative meningitis lumbar puncture shows spinal fluid charged 
with pus and bacteria, whereas in serous meningitis the spinal fluid 
contains neither pus nor bacteria; (2) Practically all cases of diffuse 
suppurative meningitis end fatally, whereas practically all cases of 
serous meningitis recover. As the symptoms of both diseases are 
otherwise about the same, it is usually difficult to differentiate the 
two diseases. Lumbar puncture should, therefore, be performed in all 
cases of suspected meningitis. 

S. J. Kopetsky has recently shown that (a) in meningitis and menin- 
geal edema the cerebrospinal fluid is acid in varying degrees, whereas 
it is normally alkaline. When the cerebrospinal fluid is acid in reac- 
tion, it is strong presumptive evidence of meningeal suppurative 
infection or meningitis. (6) The dextrose, which is normally present 
in the cerebrospinal fluid, disappears when pus and bacteria appear, 
hence the absence of dextrose, the copper reducing agent, is strongly 
indicative of suppurative meningitis. 

Acid Reagent 

fy — Five per cent, ferrichloride solution ...... 1 part. 

One per cent, carbolic acid solution 5 parts. 

M. — Sig. — Add the cerebrospinal fluid drop by drop until the first yellowish tinge 
occurs. When the yellowish tinge occurs from the addition of from one to five drops 
of cerebrospinal fluid it is indicative of meningitis. 

When the cerebrospinal fluid fails to reduce the copper in Fehling's 
solution it is strongly indicative of meningitis. 

Treatment. — The surgical treatment of serous meningitis is essen- 
tially that of decompression. Unless the symptoms point to cere- 
bellar involvement, the temporal lobe should be exposed by first 
removing the tegmen tympani et antri, and then removing the con- 
tiguous bone of the squamous plate of the temporal bone as shown in 
Fig. 518. In mild cases, and more especially in children, this will 
afford prompt relief. In severe cases it may be necessary to incise 
the dura in one or more places, or it may be necessary to puncture the 
lateral ventricle, or to perform repeated lumbar punctures. When the 
patient becomes delirious and his vital forces become greatly depressed, 
several incisions in the exposed dura should be promptly made, as 
simple decompression will not relieve the intracranial pressure. Relief 
should be expected within twenty-four hours. 

Puncture of the lateral ventricle should be reserved for very severe 
cases, though its performance need not be attended by serious con- 
sequences. It may be done with either a hollow needle, a long slender 
scalpel, or with a special dull-pointed brain knife. 



792 THE EAR 

Seromeningo-encephalitis as described by Koner, is serous menin- 
gitis plus an edema of the underlying cortex of the brain. The treat- 
ment consists of multiple incisions through the dura, as in simple serous 
meningitis, and in extending the incisions about one-half inch into 
the substance of the brain. 

Sterilized gauze should be loosely applied to the exposed dura after 
either of the above procedures, but should not be inserted beneath 
the dura. 



EXTRADURAL ABSCESS; PACHYMENINGITIS EXTERNA 
CIRCUMSCRIPTA 

Definition. — An extradural abscess is a localized or circumscribed 
pachymeningitis. The thin plate of bone between the attic and the 
dura, or between the antrum and the dura, undergoes carious and 
necrotic degeneration, and the dura over this area becomes inflamed, 
throws out a plastic exudate, and is firmly attached to the bone it covers. 
After a time the bone is destroyed and the purulent secretion burrows 
between the dura and the bone, but is prevented from extending over 
a large area by the plastic exudate. It is generally located in the middle 
fossa. 

Etiology. — The abscess usually occurs in chronic otorrhea with 
acute exacerbations of mastoiditis. It also occurs in cholesteatoma 
with suppuration. The cholesteatomatous mass in the attic or antrum 
causes pressure necrosis of the tegmen tympani and antri, and thus 
exposes the dura of the middle fossa to infection. Acute suppurative 
otitis media, especially of influenzal origin, may also cause it, as the 
bacillus of influenza is very destructive to bone tissue. An infected 
embolus or a thrombus from one of the veins or its tributaries may 
cause an extradural abscess without bone necrosis. 

Symptoms. — The signs of this condition are not well marked, a 
severe headache with a slight rise in temperature being the most reliable. 
The headache is continuous and is referred to the affected side. When, 
however, there is a sudden profuse discharge of pus from the ear, the 
headache and the temperature are relieved or disappear altogether. 
If the membrana tympani is observed by reflected light, and the pus 
pulsates in the perforation, it may be inferred that it has its origin in 
the middle fossa of the skull. That is, the pus comes from a cavity 
surrounded or partly surrounded by a resilient tissue; the dura is such 
a tissue, hence the inference. If the pus comes from a bony cavity, no 
such pulsation is present, unless an artery is exposed by the necrotic pro- 
cess. The internal carotid artery passes close to the anterior portion of 
the cochlea, and if there is a labyrinthine suppuration, and the artery is 
exposed, there may be a pulsation of the escaping pus. 

If during a mastoid operation there is a profuse discharge of pus which 
pulsates synchronously with the heart beat, there is in all probability an 



EXTRADURAL ABSCESS 793 

extradural abscess, which may be evacuated and cured by removing the 
tegmen tynipani and tegmen antri. 

Localizing motor symptoms are absent, as the motor tract of the 
brain is not involved (Fig. 424). 

The abscess is not always located in the middle fossa. Necrosis of the 
cells posterior to the labyrinth may occur, and thus communicate with 
the cerebellar fossa back of the pyramid of the temporal bone. Hence, 
vomiting and vertigo may be the prominent symptoms. The headache 
in these cases is referred to the region of the occiput on the affected side. 
The temperature is about the same as in extradural abscess of the middle 
fossa. As the disease progresses, mental dulness and coma develop 
from the increased intracranial pressure, due to the effusion into the 
ventricles. 

In a case recently operated on by the author, the patient rapidly 
developed coma during the course of an otitis media and an acute 
exacerbation of mastoiditis on the right side. The surgeon who was in 
attendance had placed the patient in a hospital for observation, and had 
recommended an operation for mastoiditis. This was refused. During 
the absence of the surgeon from the city the coma developed. When seen 
by the author, the patient was comatose. The nurse stated that he had 
been complaining of pain in the back of the head, but did not know to 
which side he referred it; a radical mastoid operation was performed 
upon the right side, and, as a cerebellar abscess was suspected, the oper- 
ation was extended in the usual way to this region, but without locating 
the abscess. At the postmortem an extradural abscess containing about 
2 drams of thin yellow pus was found on the opposite side on the posterior 
inferior aspect of the cerebellum. The left ear was not affected. 

Prognosis. — If the abscess becomes latent, and acute exacerbations 
of the otitic and mastoid inflammation do not occur, the patient's life 
may not be placed in jeopardy for a long time. If, on the contrary, 
the abscess occurs during an acute exacerbation, or following an acute 
attack of influenza, it may break its bounds and penetrate the substance 
of the brain and lead to a fatal issue. 

If the abscess is recognized, located, and successfully operated on, the 
patient usually recovers. Spontaneous evacuation into the ear or through 
the outer table of the skull may result in recovery. Knapp reports two 
such cases which evacuated near the occipital protuberance, both of 
which recovered. Dench reports 25 cases of extradural abscess, 23 of 
which recovered and 2 died. Of 12 cases occurring in the author's 
practice, 10 recovered and 2 died. 

Treatment. — The treatment is surgical; alcoholic stimulants may be 
given if sepsis is present. 

The surgical treatment of an extradural abscess consists in removing 
the plate of bone underneath which the abscess rests and evacuating 
its contents. If the abscess is in the middle fossa, it can be generally 
reached through the tegmen tympani and antri, which have already been 
exposed by the radical mastoid operation. A carious opening usually 
exists, and this should be enlarged until the plastic adhesion to the bone 



794 THE EAR 

is reached. This should not be disturbed, as to do so opens the avenues 
of infection to the healthy dura beyond it. A curved probe introduced 
through the fistulous opening in the roof of the attic or antrum will enable 
the operator to define the outlines of the abscess cavity, and he can 
thereby judge the area of bone to be removed. It will often be necessary 
to make an opening through the squamous portion of the temporal bone, 
especially in those cases due to a thrombus or an embolus, in which case 
the skull on the affected side should be trephined. If there is a point 
of tenderness, this may be utilized as a tentative means of locating 
the abscess. If after making the opening healthy dura is found, intro- 
duce a probe between the dura and the bone and pass it in various 
directions in an endeavor to locate the abscess. If the abscess is chronic 
and walled off, do not rupture the plastic barrier if it is possible to 
reach it by making an opening directly over it, as to do so may set up 
a diffused meningitis. If, however, the abscess is not directly accessible 
through an external opening, the plastic wall may be broken down and 
the pus evacuated through the opening already made by lifting the dura 
with a heavy probe or spatula and allowing it to escape. The dura 
should then be irrigated with warm bichloride solution, 1 to 5000. 

If the abscess is between the posterior wall of the pyramid and the 
dura, it may be reached through the mastoid wound by extending the 
bony wound from the posterior wall of the antrum backward and to 
the inner aspect of the sigmoid groove of the lateral sinus. If the sinus 
is large and well forward, this route is not available. The skull should 
then be trephined as shown in Fig. 518 



INTRADURAL ABSCESS; PACHYMENINGITIS INTERIOR 
CIRCUMSCRIPTA 

This condition is quite similar to extradural abscess, except that the 
dura is perforated and the plastic exudate exists between the dura and 
the arachnoid, thus walling off the purulent accumulation from the 
brain. The symptoms are the same as in extradural abscess. The 
prognosis is more grave, as the brain is in great danger of infection. 
The treatment is the same, though the probing must be more carefully 
prosecuted, as the arachnoid is more delicate than the dura. 



LEPTOMENINGITIS DIFFUSA PURULENTA OF OTITIC ORIGIN 

Leptomeningitis may arise in the course of an otitis media or mas- 
toiditis from a perforation through the tegmen tympani and antri, the 
carotid canal, the labyrinth [(a) meatus auditorius internus; (b) 
aquseductus vestibuli, (c) aquseductus cochleae], and through the 
sheaths of the anastomotic bloodvessel in influenza. Ethmoiditis and 
sphenoiditis may also give rise to it. Abscess of the brain in its later 
stages is often complicated by diffuse purulent meningitis. 



LEPTOMENINGITIS DIFFUSA PURULENT A 795 

Symptoms. — When the infection reaches the posterior fossa via the 
labyrinth and internal auditory meatus, the onset of the disease is 
sudden and is accompanied by spontaneous nystagmus directed toward 
the affected ear. Previous to this (premeningeal stage) the nystagmus, 
if happily it was observed, was toward the sound ear. In all middle- 
ear inflammations attended by giddiness, staggering gait, nystagmus, 
facial paralysis, and great tenderness over the mastoid emissary vein, 
the closest watch should be kept of the patient for spontaneous nystag- 
mus, and if found directed toward the sound ear, labyrinth involvement 
only may be diagnosticated. If it reverses its direction while under 
observation, it marks the onset of meningitis. If the reversal is not 
observed, but the nystagmus is toward the diseased ear, a tentative 
diagnosis of meningitis in the posterior fossa may be made. 

Headache, at first remittent and later constant, is characteristic of 
this disease. The temperature is elevated and face flushed. The pulse 
ranges from 120 to 140, and the respirations are rapid, the latter 
assuming the Cheyne-Stokes type as a fatal issue is approached. Per- 
sistent vomiting of mucus and bile is present. Mental excitement, 
such as irritability, delirium, and extreme restlessness are marked 
symptoms; as the disease progresses, somnolence and loss of memory 
develop. Rigors are present, but not so marked as in sinus thrombosis. 

The pupil on the side affected is often contracted, and occasionally 
the one on the opposite side. Choked disk, papillitis, and optic neuritis, 
while not always present, are often present. 

The muscles of the face and extremities become drawn or contracted, 
but these phenomena finally centre in the muscles of the neck, and the 
head is retracted. The muscles of the abdomen are drawn in and 
the abdomen flat. The motor oculi, trochlear, and abducens nerves 
become paralyzed. 

Spinal involvement is shown by Westphal's symptoms, viz., increased 
tendon reflexes and paresthesia and hyperesthesia of the extremities. 

By Quincke's lumbar puncture, the increased pressure increased 
coagulability and the presence of bacteria may be determined. The 
virulence of the bacteria may be tested by inoculating a guinea-pig with 
them. Coma occurs a few hours before death. In the early stage lum- 
bar puncture may furnish the only reliable data for a positive diagnosis. 
The presence of pus and bacteria without other diagnostic symptoms 
would warrant a diagnosis of meningitis. An early Haynes operation 
upon the cisterna magnum might effect a cure. (See Lumbar Puncture.) 

Prognosis. — Death occurs in nearly every case. Operative inter- 
ference is not warranted, unless, indeed, Haynes' operation upon the 
cisterna magnum is resorted to. 

Treatment. — The treatment of purulent meningitis is essentially 
surgical, though the results of such treatment have been almost uni- 
formly unsuccessful. Several cases thus treated have been reported 
as cured, but in all probability they were serous in character. Never- 
theless, surgical treatment appears to be the only rational method at 
our command. The chief difficulty is anatomical, namely, the purulent 



796 THE EAR 

exudate penetrates the subdural and subarachnoid spaces, where it 
becomes more or less organized, and as a consequence does not drain 
away, even when the whole area is exposed by the removal of the 
bone and numerous incisions are made in the dura. The same difficulty 
attends Hay lies' operation upon the cisterna magnum. (See Hay lies' 
Operation.) As I have already said, all operative measures have thus 
far, with a few possible exceptions, proved futile, insofar as a cure 
is concerned. Many cases are, however, relieved of the delirium and 
coma, and spend their last hours in comparative comfort, with a reason- 
ably clear intellect, a point of considerable sentimental and medicolegal 
importance. 

The treatment consists in exposing the dura over the affected area, 
and removing the tegmen or the squamous plate of the temporal bone 
as in serous meningitis. (See Treatment of Serous Meningitis.) If the 
cerebellum is involved a plate of bone should be removed as shown in 
Fig. 518. When the dura has been thus uncovered several incisions 
should be made in it. Loose dressings of gauze should be applied 
daily under the strictest antiseptic precautions. 

Haynes' Operation. — This operation is based upon the theory that 
in meningitis there is a constant high intracranial pressure, and that 
the natural drainage pathways are blocked. He proposes by open- 
ing the cisterna magnum to relieve the high pressure, and at the same 
time unblock the arachnoid pathways for drainage. His operation 
undoubtedly does both of these things, but unfortunately the purulent 
exudate is coagulated and entangled in the subdural and subarach- 
noid spaces, and is physically unfit to drain away. As a consequence 
the operation has thus far proved very disappointing, except in cases 
that were probably serous in character. Dr. Ewing W. Day has 
reported nine cases, all of which ended in death; Dr. J. C. Beck, seven 
cases, all but one of which died; Dr. Emerson, one case, which recovered, 
and which he now regards as serous meningitis. Haynes, Kopetsky, 
Phillips, and others have reported cases with similar results. This 
operation seems to offer little or no advantage over the exposure of 
the dura in the temporal and cerebellar areas. It does, however, afford 
a better chance for drainage, and is therefore to be preferred to the 
other operations. Subsequent experience and improved technique, 
which can only be gained by continuing to do the operation, may 
show better results. 

Technique. — 1. The preparation of the patient consists in shaving 
the entire head and sterilizing it, the neck, and contiguous areas of 
skin. The patient is then placed face downward on the operating 
table, with the head flexed upon the sternum over sand bags or the 
end of the table. 

2. The anesthetic preferred by Haynes is ether administered through 
a nasal tube, by the warm spray method, beneath a sterile sheet cover- 
ing the patient. The variations of the pulse and respirations are con- 
stantly watched during the entire operation by an assistant especially 
detailed for this purpose. A sphygmomanometer is applied, and its 
fluctuations carefullv noted bv the assistant. 



LEPTOMENINGITIS DIFFUSA PURULENTA 



797 



Fig. 420 




The incision in Haynes' operation. 



Fig. 421 




The skin and periosteum elevated, and an opening trephined through the bone at the upper 

angle of the vound. 



798 



THE EAR 



3. The skin incision extends from the occipital protuberance to 
the spinous process of the axis (Fig. 420), and is rapidly carried down 
to the occipital bone and posterior arch of the atlas. Bleeding arteries 
and veins are tied as they are encountered. The periosteum and 
overlying muscles are elevated on either side of the incision, thus 
making, when retracted, a field about one and one-half to two inches 
long, and one inch wide (Fig. 421), the widest portion being at the 
posterior margin of the foramen magnum. 

4. Opening the skull is accomplished with a De Vilbiss trephine 
three-eighths of an inch in diameter (Fig. 421). The trephine should 
be located about one inch behind the posterior margin of the foramen 
magnum, and the button of bone removed. This opening should be 
enlarged forward to the foramen magnum with a De Vilbiss bone 
forceps, and should be made wider and wider as it approaches the fora- 
men, thus forming a V-shaped opening as shown in Figs. 421 and 422. 



Fig. 422 




Incision through the dura. 



5. The incision of the dura should only be done after locating the 
occipital sinus, or sinuses, as the case may be. In some cases it is 
single, while in others it is double. The incision should include only 
the dura, and should be made as long as possible without injuring 
the occipital sinus (Fig. 422). 

6. The arachnoid should now be punctured with the point of the 
bistoury, the fluid escaping under high pressure, often rises several 
inches into the air. Some of the fluid should be caught in a test-tube 
for examination. The arachnoid incision should now be made 



ABSCESS OF THE BRAIN 



799 



coextensive with the dural incision (Fig. 423). A sphygmomanometer 
should be applied throughout the operation, and when the fluid escapes 
the change in blood pressure should be noted. 



Fig. 423 




The arachnoid incised and the cisterna magnum opened. 

The dressing advised by Haynes is made of accordion pleated rubber 
tissue, which is inserted one-quarter of an inch into the cisterna mag- 
num (Fig. 423). One or two sutures are used to bring the soft parts 
together. The outer dressings are changed daily, or as often as they 
become saturated. 



ABSCESS OF THE BRAIN 1 



General Considerations. — Brain abscess following middle-ear or mas- 
toid disease, may present a typical train of symptoms of an infective 
process combined with a tumor formation within the cranial cavity 
in which definite localizing symptoms are present, consequently ren- 
dering the diagnosis an easy and simple matter. In other cases of 
chronic encapsulated abscess there may be an entire absence of any 
localizing symptoms, and the general symptoms may be so indefinite 
that the surgeon may not suspect the real nature of the trouble, hence 
making a definite diagnosis impossible; however, taking into consider- 
ation that there is a history of middle-ear disease, combined with 
some general symptoms of toxemia, such as prolonged exhaustion 

1 Revised and largely rewritten by Dr. Howard Charles Ballenger. 



800 THE EAR 

or emaciation with no explainable cause, the surgeon may suspect an 
intracranial complication, although he may be unable to localize it. 

Etiology. — Abscess within the cranial cavity may be due to a num- 
ber of conditions, of these only one will be considered in this chapter, 
namely, those abscesses secondary to middle-ear or mastoid disease. 
Of all etiological factors concerned in producing brain abscess, disease 
of the tympanum antrum and labyrinth is the most common. 

The extension of the middle-ear diseases to the cranial cavity depends 
upon the vulnerability of the natural barriers separating the middle 
ear from the cranial cavity, namely, the bone and its lining mucous 
membrane of the middle ear and antrum. Hence it is in those long- 
continued middle-ear suppurations that the vitality and protective 
ability of these natural barriers are more apt to be impaired or destroyed 
and an easy avenue of entrance to the cranial cavity established. 
It has been shown by the statistics of Neumann, Okada, Grunert, and 
others that approximately 85 per cent, of brain abscesses come from 
the chronic form of middle-ear suppuration. 

The most susceptible age of attack usually falls within the limit 
of the tenth to thirtieth years of life. 

Men are more frequently affected than women. In Neumann's 
188 collected cases, 127 were men and 61 were women. Of Koerner's 
204 collected cases, 136 were men and 68 were women. 

By far the greatest number of otitic brain abscesses are found in 
the temporosphenoidal lobe, the cerebellum being second in the fre- 
quency of attack, the pons and crura cerebri being a comparatively 
rare location for abscess. According to the statistics (Kerrison) as 
given below we find out of a total of 1400 cases in which the abscess in 
the rarer situations, such as pons and crura cerebri are left out, that 
930 or, approximately, 70 per cent, involve the cerebrum, and that 
470 or, approximately, 30 per cent, involve the cerebellum. 

Total number cases. Temporal lobe. Cerebellum. 

Barr 



Koerner 
Hermann 
H. Todd 

Neumann 



55 (81 per cent.) 13 (19 per cent.) 

119 79 (67 per cent.) 40 (32 per cent.) 

581 395 (68 per cent.) 186 (32 per cent.) 

100 65 (65 per cent.) 35 (35 per cent.) 

532 336 (63 per cent.) 196 (37 per cent.) 



Various investigators have shown that a streptococcic infection of 
the middle ear is more apt to result in an intracranial infection than 
is any other one microorganism. 

Ruttin has called attention to Streptococcus mucosa capsulatus as 
an exceedingly virulent organism which if left unchecked will go on 
in many cases to intracranial complications. 

Pathology. — The spread of infection from the diseased ear to the 
brain may occur in various ways; probably the most frequent avenue 
of entrance is by way of the tegmen tympani, which usually results 
in an abscess located in the temporosphenoidal lobe. A long-con- 
tinued suppurative process within the middle ear may result in an 



ABSCESS OF THE BRAIN 801 

erosion and perforation of the tegmen tympani and a consequent 
localized inflammation of the dura mater. According to Macewen 
the visceral surface of the dura has, at a point corresponding to the 
osseous erosion, a raised projection of granulation cells and plastic 
effusion, generally somewhat conical in shape, with its obtuse extremity 
pointing upward, and forming an indentation on the surface of the 
brain, the pia mater usually being adherent to it. This conical mass 
of granulation tissue and inflammatory exudate later forming a direct 
pathway from the middle ear to the brain substance. 

As a result of the extension of the infection to the pia mater and 
brain, the veins and lymphatics of the former may become directly 
affected and in some cases result in thrombosis of the terminal cerebral 
vessels; the infected thrombus later giving rise to a cerebral abscess, 
located at some distance from the point of entrance into the cranial 
cavity. 

The cerebellar fossa is most prone to attack from a suppurative 
process in the mastoid by way of the sigmoid groove, the majority of 
these cerebellar abscesses remaining in contact with the sigmoid sinus. 

Frequently a thrombus forms in the sigmoid sinus corresponding 
to the site of the bony erosion, due to an associated inflammatory 
condition of the inner surface of the sinus wall. 

Infection may gain entrance into the labyrinth through necrosis of 
the external semicircular canal, through the fenestra ovalis, through 
the promontory or the fenestra rotunda; and from the labyrinth the 
infection may pass to the meninges by way of the meatus auditorius 
internus, aquseductus vestibuli, or aquseductus cochleae. The increasing 
attention which is now being paid to suppurative labyrinthitis and its 
recognition may result in establishing a much greater frequency than 
formerly supposed, of the role of the labyrinth in producing abscess of 
the brain, especially of the cerebellum. Neumann says that in two- 
thirds of all abscesses of the cerebellum the labyrinth is involved. 

A brain abscess may vary in size from that of a pea to one capable 
of displacing an entire lobe of the brain. 

An abscess usually has an encapsulating membrane due to the more 
or less inflammatory process of its development, although an entire 
absence of any fibrous retaining wall has been noted (Neumann). 

Symptoms. — Macewen divides the symptoms and the course of the 
disease into three stages, and this classification will, in a general way, 
be followed. 

First or Initial Stage. — In this stage the predominant features are 
those of toxemia rather than of a tumor formation, and when seen by 
the surgeon, an abscess formation may not be anticipated. The patient 
usually gives the history of a long-continued, purulent discharge from 
the ear. He may have become ill from the abscess rather suddenly. 
Pain is nearly always complained of. It is usually confined to the 
region of the abscess, although it may be referred to the frontal or 
occipital regions irrespective of the location of the abscess. The pain 
is usually of an excruciating character or may be of the neuralgic tvpe. 
51 



802 THE EAR 

Vomiting frequently occurs during this stage and bears no relation 
to the taking of food. It may be unaccompanied by nausea. 

A chill is one of the fairly constant early symptoms. It may vary in 
intensity from a slight sense of coldness to a most violent shaking, 
and may endure from a few moments to an hour or so. 

The temperature is somewhat elevated and the pulse faster than 
normal. 

The otorrhea may cease or become less in quantity. 

In a few hours or several days the symptoms of the acute stage 
usually abate and a period of quiescence or the latent stage as scn:e 
authors classify it, may ensue. The patient may apparently be in 
normal health and be able to pursue his usual vocation. This latent 
period may last only a few days or may extend over a period of weeks 
or months, but sooner or later signs of increasing intracranial pressure 
will become manifest. 

Second Stage or Stage of Increasing Intracranial Pressure. — As the 
abscess takes form and gradually increases in size, the pressure within 
the cranium is more and more increased. 

The patient may complain of a dull, persistent headache in the region 
of the affected lobe, or he may have a slight pain referred to the frontal 
or occipital region. Percussion of the affected side may elicit some 
tenderness, but the pain and headache may not be present, the patient 
appearing to be in a fairly comfortable condition. 

Mental Lethargy. — As the abscess increases in size, and consequently 
increases intracranial pressure, there is a retardation of cerebration in 
which the patient will consume several times the usual length of time 
in any simple mental process, such as answering questions and the like. 
His attention will not be sustained for any length of time. He appears 
drowsy and easily drops into a somnolent condition, although unable 
to get any refreshing sleep. 

Loss of Motor Will Power. — The patient may give the impression of 
a profound weakness during this stage which is not based upon a lack 
of muscular strength, but is rather due to a lack of motor will power. 

Temperature during the second stage in uncomplicated cases is 
normal or slightly subnormal, in marked contrast to other intracranial 
complications. 

The pulse is slow, usually fifty to sixty per minute, and is of good 
volume. 

Respirations are slow and usually regular. 

Vomiting usually does not occur during the second stage, although 
it may be present, and when associated with a persistent headache is 
very suggestive of intracranial disease (Macewen). Vomiting asso- 
ciated with a persistent headache is more frequently a later symptom 
of tumor and meningitis, than of abscess, in which latter condition 
these symptoms more often occur early in the initial stage of the 
disease. The remittent type of vomiting is more apt to result from 
cerebellar than from cerebral abscess. 

Emaciation of a profound degree frequently occurs in brain abscess 



ABSCESS OF THE BRAIN 803 

during the latter part of the second stage. The presence of an unex- 
plained loss of flesh and strength combined with an entire absence of 
any fever, especially when bradycardia is present, is very suggestive 
of a cerebral abscess. 

Constipation is the rule and may be very obstinate 
The urine frequently is retained, and occasionally shows albumin. 
Sugar is absent unless the location of the abscess is in the pons or the 
medulla oblongata, in which "case sugar is frequently present. 

Localizing Symptoms. — Convulsions seldom occur in abscess of the 
brain, and when they are present are probably due to a leakage of the 
abscess with a consequent localized meningeal irritation. When a 
localized spasticity of some muscle or group of muscles is present, it 
affords valuable aid to diagnosing the location of the abscess ; however, 
it should always be taken into consideration that the irritation of the 
motor centres involved may lie at some distance from the abscess. 

Fig. 424 



X 




; ; .'"./' 



The cortical centres of the cerebrum, to be used in localizing lesions within the skull. 

Paralysis when present is of much aid in diagnosing the location 
of the abscess, as it usually depends upon direct pressure of the motor 
centres or pathways involved, or upon the more or less destructive 
process produced in the immediate inflammatory zone surrounding 
the abscess. Hemiplegia on the side opposite to the lesion has been 
noted in large temporosphenoidal abscess. Frequently the abscess 
is located near the arm or leg centre, with the resulting paralysis of 
one or both of those members (Fig. 424). Contralateral facial paralysis 
may occur in certain temporosphenoidal abscesses, although it is 
possible for the paralysis to be homolateral from direct involvement 
of the peripheral nerve itself. Paralysis of the third nerve and adductor 
muscles of the eyes on the same side may occur, although this paralysis 
is rarely complete. The pupil may be either myotic or mydriatic, 



804 THE EAR 

that is, contracted or dilated; usually a small abscess with some cere- 
bral irritation, producing a more or less contracted and sluggish pupil, 
and a large abscess with the consequent increased pressure resulting 
in mydriasis. 

Aphasia may be looked for in certain cases in which the cortical 
speech centre of the left temporosphenoidal lobe is involved. The 
aphasia may be either sensory or motor. The most common speech 
defect is that form of sensory aphasia known as word deafness, in 
which the patient recognizes the form of the object and its uses, but is 
unable to recall its name. 

Optic neuritis, papillitis, and choked disk are sometimes found in 
the latter part of the second stage of large abscess of a more or less 
chronic nature, especially those abscesses involving the cerebellum. 
These eye-ground changes are not so frequent in brain abscess as in 
certain other intracranial affections such as meningitis and slow-growing 
tumor. 

Terminal Stage. — If the disease is allowed to pursue its own course 
it ends, as a rule, in death. This may occur in one of at least two 
ways. 

(a) By a gradually deepening stupor and coma followed by death. 

(6) By rupture of the abscess into the ventricles and subarachnoid 
spaces producing a more or less diffuse suppurative leptomeningitis, 
from which death results within one or two days. 

Diagnosis. — Bacon emphasizes the significance of a firm, dense, 
mastoid process in the cases operated, in which such symptoms as 
high fever, rapid pulse, etc., do not abate after the operation. He thinks 
it points to cerebral complications, and should lead the operator to 
explore the cranial cavity without further delay. If the pus and debris 
are removed and drainage is established, the symptoms should at once 
become better, and they should remain so. If, on the other hand, only 
the outer pus pocket (mastoid antrum) is evacuated, while the inner pus 
pocket (brain abscess) remains closed, the septic symptoms will con- 
tinue. The needlessness of delay in operating, or doing secondary 
operations upon the cranial cavity, when the septic symptoms con- 
tinue without abatement cannot be too strongly impressed. The 
dangers attending the exploration of the cranial cavity are small com- 
pared with those of delay. 

When, after a mastoid operation, the fever and pain continue and 
the examination of the fundi of the eyes is negative, the surgeon should 
not be misled by the negative findings, as many cases are reported in 
which the subsequent history showed brain involvement to have been 
present. 

J. F. McKernon writes that when the occipital pain is not relieved 
by the primary mastoid operation, the aural surgeon should go deeper 
and explore the cerebellar area, in order, if possible, to determine the 
cause of the pain. He recommends a grooved director for exploring 
the brain substance in place of an aspirating needle, as it allows the 
thick pus to escape, whereas an aspirating needle does not. 



ABSCESS OF THE BRAIN 805 

McKernon formulates the following indications for exploring the 
cranial cavity when an otitic abscess is suspected: 

1. That a chronic otorrhea is or has been present. 

2. Persistent headaches, general or localized. 

3. Restlessness and irritability of temper. 

4. Tenderness of the affected side on percussion. 

5. Vomiting, and vertigo. 

6. An almost persistently low temperature. 

7. A slow pulse, later stupor. Optic neuritis may or may not be 
present, when present it may aid materially in arriving at a diagnosis 
as may also aphasia and motor disturbances. 

He believes head pain (2) is the most significant symptom. 

"In the great majority of cases, other than traumatic or pyemic, 
the patient has had a chronic purulent discharge from the middle 
ear, often dating from an attack of one of the exanthematous fevers 
of childhood, or he has had a chronic ulceration about the nose or 
mouth." (Macewen.) 

The otorrhea may have given little trouble, and its long continuance 
without apparent harmful result may have lulled the initial fear, until 
the ear disease is regarded as of no importance. 

A person thus affected may suddenly become seriously ill after 
unusual exposure or injury to the head, or even without any known 
cause. Persistent headache develops without any increase in the 
pus discharge. Other symptoms follow, and the patient applies to 
his physician for relief. 

There may be a fistula in the tegmen tympani, which has existed 
for years without infection of the meninges. The granulations fill 
the opening and effectually guard the intracranial contents from 
infection. Such a favorable result is not always to be expected. In 
removing the granulations from the attic through the external meatus, 
great care should be exercised lest a perforation in the tegmen be 
thereby opened and septic infection transmitted to the meninges. 

Differential Diagnosis. — In acute cases one must distinguish between 
abscess, encephalitis, meningitis, and septic sinus thrombosis. The 
chronic cases may be mistaken for tumors, since the pressure symptoms 
are similar in both. The evidence of brain pressure, stupor, slow 
pulse, and subnormal temperature are more frequently associated 
with an intracranial abscess than with meningitis or encephalitis. 
Cervical rigidity and Kernig's sign, are more characteristic of menin- 
gitis than abscess. In meningitis the cerebrospinal fluid obtained by 
a lumbar puncture even if bacteria are absent, shows an increased 
number of leukocytes (Starr). This is not true of abscess unless it be 
complicated by meningitis. In septic thrombosis of the sigmoid sinus 
the high temperature with its marked remission, rapid, weak pulse, 
recurrent rigors, followed by profuse sweating, and the pain in the 
submastoid region and down the course of the affected jugular should 
enable the surgeon to make a differential diagnosis. 

Sometimes it is necessary to differentiate between abscess and 



806 THE EAR 

tumor of the brain. The absence of a history of a suppurative process 
in the temporal bone, the slow progress of the symptoms, the pro- 
gressing involvement of the cranial nerves, the absence of rigors, and 
the intense degree of optic neuritis should all point to tumor. 

Prognosis. — The natural termination is death. Surgical inter- 
ference often arrests this if done in the first or second stage. Koerner 
reported 92 cases of brain abscess operated upon with 51 recoveries. 
The prognosis depends somewhat upon the bacteria which may be 
present. If the examination of the pus from the abscess reveals a 
streptococcic or anerobic bacteria, the prognosis is bad, if diplococcic 
bacteria are present the prognosis is better. 

The prognosis also varies according to the stage in which the opera- 
tion is performed. If seen and operated in the first stage the death 
rate should be small, perhaps less than 10 per cent., if in the early 
part of the second stage it should not exceed 50 per cent. Accord- 
ing to Macewen, u an uncomplicated cerebral abscess, whose position 
is clearly localized, if surgical measures are adopted for its relief at a 
sufficiently early period, is one of the most hopeful of all cerebral 
affections." 

Treatment (see Surgery of the Temporal Bone). — The most impor- 
tant of all therapeutic measures is prophylaxis, hence, the early radical 
treatment of extracranial suppurative processes is the best preventative 
for these intracranial complications. 

However, the general condition of the patient should receive care- 
ful attention such as prevention of constipation and coughing, as the 
straining incident to these two conditions may produce a prolapse of 
the brain. 



CEREBELLAR ABSCESS 

Cerebellar abscess in the early stage, or when the abscess is small, 
gives rise to few localizing symptoms, and, hence, is very difficult of 
diagnosis. When the abscess is large, or when there is an associated 
meningitis of the cerebellar fossa, there is a more characteristic train 
of symptoms. Abscess in the region of Bechterew's nucleus and of 
the third and sixth oculomotor centres, may give rise to characteristic 
symptoms such as vomiting, giddiness, nystagmus, ataxia, and oculo- 
motor paralysis. 

Symptoms. — General Symptoms. — The general symptoms are similar 
to those described under Brain Abscess in the preceding pages, and 
only a brief resume will be given. 

Pain and headache is usually found in the occipital region on the 
side of the abscess or in some cases referred to the frontal region. It 
is usually more persistent and more severe than is found in temporo- 
sphenoidal abscess. 

Neumann says the pain is usually frontal or four finger-breadths 
back of the ear. 



CEREBELLAR ABSCESS 807 

Vomiting is especially common in cerebellar abscess, and when it 
persists throughout the second stage special attention should be 
directed to the cerebellum. 

The temperature after the initial rise, becomes normal in uncom- 
plicated cases. 

The pulse is abnormally slow. 

The respiration is normal or slower than normal. 

Prostration and depression with no assignable cause is a predominant 
feature of cerebellar abscess. 

Yawning frequently occurs as the pressure of the cerebellar abscess 
is increased. 

Focal Symptoms. — Retraction of the head and neck forward and to 
to the diseased side occurs when there is some associated meningeal 
inflammation (Neumann). 

Facial paralysis may occur on the same side as the abscess, due to 
the direct involvement of the peripheral nerve. 

Changes in the eye-ground, papillitis, optic neuritis, and choked disk, 
are more frequently associated with cerebellar than with cerebral 
abscess. 

Subjective vertigo is a fairly constant symptom of cerebellar involve- 
ment. This vertigo, unlike that of labyrinthine disease, bears no 
relation to the nystagmus (see chapter on the Labyrinth) . The dizzi- 
ness or vertigo is usually very persistent and may be present when 
nystagmus has disappeared. 

The nystagmus in cerebellar abscess is usually rotatory and may 
be directed to either side, that is, the quick component may be directed 
to the diseased side, or may be to the normal side. (See Plate XVII.) 
It is usually to the diseased side. It may change its direction and be 
first to one side and then to the other, for instance, with the eyes turned 
toward the right side the nystagmus will be to the right, and conversely, 
if the eyes look toward the left side the nystagmus will change and 
also be to the left. This changing nystagmus when present, being in 
marked contrast to the nystagmus of labyrinthine disease, which does 
not change in direction when the eyes are voluntarily turned except 
in some cases of circumscribed labyrinthitis. Cerebellar nystagmus 
does not show any tendency to diminish, but rather to increase in 
severity as the disease progresses, giving another valuable aid in 
differentiating a cerebellar nystagmus from that produced by a disease 
of the labyrinth, in which latter condition the nystagmus tends to 
gradually subside after loss of function, and usually disappears in from 
a few hours to three weeks. The nystagmus may not be manifest until 
opaque glasses are applied to the eyes. 

Disturbance of equilibrium is sometimes very marked in abscess of 
the cerebellum, indeed to such a degree that the patient is unable to 
remain in the upright position without falling. Other cases may show 
a comparatively small impairment of the sense of equilibrium, the only 
noticeable evidence being a slight spreading of the legs or a turning 
out of the toes in order to gain a broader base of support. There 



THE EAR 

is a tendency to fall backward or laterally in the direction of the side 
of the lesion, according to whether the abscess is situated in the vermis 
or in a hemisphere. 

The loss of the sense of position, or of the arthrodial sense, may be 
demonstrated in some cases. This is done by having the patient 
passively move an arm or leg corresponding to the side of lesion, while 
blindfolded or with eyes closed, and then arresting the arm or leg in 
some unusual position. If the arthrodial sense is impaired he will be 
unable to assume the same position with the opposite arm or leg. 

The Pointing Test. — Barany, of Vienna, has shown that if a normal 
person is blindfolded, or closes his eyes, after having previously deter- 
mined the location of some object held in a stationary position, he is 
able to lower or raise his arm and touch the object. If the patient 
harbors a cerebellar abscess with focal symptoms, the hand corre- 
sponding to the side of the cerebellar lesion frequently deviates to one 
or the other side, while the other hand or arm corresponding to the 
normal side is able to point fairly correctly. With vestibular disturb- 
ance both hands deviate in the same direction, i. e., in the direction of 
the slow component of the nystagmus. 

Disturbance of motility is frequently present in cerebellar abscess. 
This may be noticed in the affected parts as awkwardness, tremors, 
incoordination, etc., or the disturbance of motility may take the form 
of "excessive movements." If, for example, the patient carries the 
point of his index finger toward the end of his nose it does not stop 
when the nose is reached but passes over it and violently strikes the 
jaw. 

Babinski has drawn attention to the disturbances of diadokokin- 
esis or the ability to execute rapidly successive volitional movements. 
Adiadokokinesis is the loss of this faculty. For example, if the patient 
be directed to rapidly supinate and pronate both hands and fore- 
arms, the hand corresponding to the cerebellar lesion will be greatly 
retarded, or if he is asked alternately to flex and extend the forearm 
upon the arm, movements of the arm corresponding to the cerebellar 

PLATE XVII. 

Showing Spontaneous Nystagmus of (A) Vestibular Origin, and (B) of Central or 
Cerebellar Origin. 

(A) The serous labyrinthitis affecting the right ear inhibits the labyrinth upon 
that side and leaves a preponderance of tonus in the left labyrinth. This causes a 
slow conjugate movement of both eyes to the right (slow component); the cortical 
reflex immediately turns the eyes to the left (quick component) and the nystagmus 
thus produced is spontaneous rotatory vestibular nystagmus to the left. The red 
arrows indicate the course of the vestibular impulses which give rise to the slow 
component of the nystagmus. 

(B) The cerebellar abscess stimulates the right Deiters' nucleus (D. N.), and 
thereby increases the tonus on the right side. The increased tonus causes a con- 
jugate movement of both eyes to the left (slow component) and the cortical correc- 
tive impulse immediately turns the eyes to the right (quick component) and the 
nystagmus is spontaneous rotatory cerebellar nystagmus to the right or side of 
disease. The blue arrows indicate the course of cerebellar impulses whioh give rise 
to the slow component of the nystagmus. 



PLATE XVII 




(A) Vestibular Nystagmus; (B) Cerebellar Nystagmus. 



THROMBOSIS 809 

lesion will be slower and less regular, although the muscular force is 
preserved and sensibility is intact. 

Disturbance of speech is sometimes present in abscess of the cere- 
bellum. The voice may be nasal and the words emitted with sudden- 
ness or the articulation may be slow and thick. 

Treatment (see Surgery of the Temporal Bone). 

THROMBOSIS 

A thrombus is a mass formed in the heart or peripheral vessels, the 
component parts of which are derived from the blood (Frazier). They 
are arterial, venous, capillary, or cardiac in origin, and, according to 
to their composition, are white, red, and mixed thrombi. 

The following four factors enter into the pathogenesis of a thrombus : 

1. Infective microorganisms. 

2. Structural changes in the intima of the vessel or organ. 

3. Disturbances of the blood current. 

4. Chemical changes in the blood. 

1. In the non-infective thrombus the microorganisms are absent. It 
is the infective type, however, with which the otologist has to deal . " The 
primary causative factor is a pyogenic organism, a primitive lesion, a 
phlebitis, and the terminal process a thrombosis or a thrombophlebitis. 
Thrombophlebitis, associated with such general septic processes as 
pyemia and septicemia, was the first to be recognized as of infective 
origin; subsequently, however, the infective nature of thrombophlebitis 
has been admitted and recognized in other diseases of infectious origin, 
as in the various so-called infectious diseases" (Frazier). Streptococci 
are the most frequent cause of this disease. A negative bacteriological 
finding does not necessarily preclude an infectious origin, the toxin 
remaining being the exciting inflammatory agent. 

2. The structural changes in the intima are due to the irritation by the 
toxins of the bacteria. The intima becomes rough and adhesive. The 
injured cells of the intima liberate a fibrin ferment which favors thrombus 
formation. The roughened projections of the intima into the lumen of 
the vessel interfere with the velocity of the blood current and thereby 
favor thrombus formation. 

3. The slowing of the blood current cannot alone cause thrombosis. 
If associated with changes in the intima and the presence of micro- 
organisms, it predisposes to thrombus formation. The slowing of the 
blood current is attended with a rearrangement of the constituents of 
the blood. The white blood corpuscles incline to the periphery of the 
current and are admixed with a few platelets. As the current becomes 
slower, the white corpuscles diminish and the platelets increase in num- 
ber. In some instances a projection from the intima causes a whirling 
motion of the current, which still further favors thrombus formation. 

4. The chemical changes in the blood, while not yet demonstrated, seem 
to be a factor in thrombosis. A fibrin ferment is probably liberated in the 
infected thrombus, and it may influence the production of the platelets. 



810 THE EAR 

Pathology. — The thrombus is composed of the constituents of the 
blood in varying proportions, and are white, red, or mixed, according to 
whether they are formed in circulating or stagnant blood. If in circu- 
lating blood, they are white or mixed; whereas, if in stagnant blood, 
they are red, and have no clinical significance. Blood platelets form the 
nucleus of the white and mixed variety, though in the later stages they 
may have disappeared. 

According to Frazier, the thrombus, at first composed of the normal 
constituents of the blood, undergoes various changes, which become an 
element of considerable danger. The leukocytes undergo fatty degen- 
eration and necrosis; the red corpuscles are decolorized, irregular in 
shape, and pigmented. The platelets disappear and are replaced by 
fibrinous deposits. Softening or liquefaction occurs, and the creamy sub- 
stance contains granular debris, pus cells, and microorganisms. It is 
in the septic variety of softening that fragments become separated from 
the thrombus, and, as infected emboli, are carried off by the circulation 
and deposited in the internal organs, usually the liver, kidneys, and lungs, 
where they give rise to secondary or embolic abscesses. 

The terminal stage of a thrombus is organization, or rather a disap- 
pearance of the thrombic material and the deposit of fibrous material. 
At the beginning of organization the thrombus becomes infiltrated with 
leukocytes, and following this there is a proliferation of fixed connective- 
tissue cells derived from the endothelium and the other fixed cells of the 
intima. Bloodvessels penetrate the clot and form anastomoses with 
each other and with the vessels above and below the thrombus. The 
thrombus is absorbed, and is replaced by embryonic connective tissue 
rich in bloodvessels. The fibrous mass becomes firm, contracts, and 
may completely or partially occlude the vessels. In rare instances the 
fibrous tissue disappears and leaves the lumen of the vessel unimpaired. 

Venous thrombi extend toward the heart or with the blood current. 
In thrombosis of the sigmoid or petrosal sinuses, the thrombus may 
extend to the jugular vein and completely occupy its lumen. 



LATERAL SINUS THROMBOSIS 

Etiology. — The causes of infective thrombosis of the sigmoid portion 
of the lateral sinus are chiefly to be found in the loss of integrity of the 
intima of the membranous sinus from the extension of the destructive 
process in suppurative mastoid or labyrinthine inflammation. So long 
as the intima is healthy it inhibits the coagulation of the blood in con- 
tact with it, but where its vitality is impaired by a necrosing mastoiditis 
its inhibitory power is lost and the blood fibrin coagulates on the affected 
area, and a thrombus is thus established. The thrombus may or may 
not occlude the lumen of the vessel. At the beginning it is limited to the 
external or bony aspect of the sinus, as this is the part first involved by 
the necrosis of the bone. The necrosis may extend from the mastoid 
cells of the process or from the labyrinth (in labyrinthine suppuration) 



LATERAL SINUS THROMBOSIS 



811 



Fig. 425 




Schema showing venous sinuses of the head. (After Macewen.) 



812 THE EAR 

to the cells lying between the labyrinth and the antrum, and thence to 
the antrum and mastoid cells, from whence it involves the sinus. 

At the beginning the thrombus is not infected. It is only after the 
wall of the membranous sinus has undergone marked deterioration that 
the infective microorganisms penetrate it and lodge in the thrombus. 
There is food for thought in this fact. That is, if the condition is diag- 
nosticated before infection of the thrombus occurs, the infection and its 
evil consequences could be thwarted by an exposure of the sinus and the 
removal of the diseased bone surrounding it without opening the sinus 
itself. Unfortunately, the diagnosis of thrombosis at this early stage is 
extremely difficult to make, and is rarely made except during a mastoid 
operation. 

Symptoms. — The symptoms of lateral sinus thrombosis may be 
divided into three stages, based upon the pathological changes so 
minutely described by Macewen in his masterly work on The Pyogenic 
Diseases of the Brain and Spinal Cord. 

First Stage. — The thrombus, partial or complete; disintegration not 
established. 

(a) Slight fever. 

(b) Rigors, usually present. Slight rigors exceptional 

(c) Headache, slight or severe, limited to the affected side. 

(d) Slight tenderness over the region of the mastoid emissary vein. 

(e) Slight edema and tenderness below the tip of the mastoid in the 
posterior triangle of the neck. 

(/) Leukocytosis with increased polymorphonuclear count. 
Second Stage. — The thrombosis, partial or complete; disintegration 
and systemic absorption established. 

(a) Temperature always above normal and distinctly fluctuating. 

(b) Frequent rigors. 

(c) Headache and tenderness over the mastoid emissary vein. 

(d) Edema and tenderness below the tip of the mastoid in the pos- 
terior triangle of the neck. 

(e) Increased leukocytosis and polymorphonuclear count 

Third Stage. — The thrombosis, partial or complete; disintegration and 
excessive systemic absorption. 

(a) A chill or rigor followed by great and marked fluctuations of 
temperature; sometimes subnormal, and then rapidly rising to 104° 
or 106° F. 

(b) Headache, severe, often excruciating, 

(c) Marked tenderness over mastoid emissary vein and the posterior 
triangle of the neck. The internal jugular vein may be tender on pressure. 

(d) Metastatic pneumonia, enteritis, or meningitis may be present, 
with characteristic symptoms. 

(e) Still greater leukocytosis and polymorphonuclear count. 

Note. — The leukocytosis and polymorphonuclear count is greater in 
sinus thrombosis than in simple mastoiditis, 
(/) Coma as the fatal issue approaches. 
Early Diagnosis. — If diagnosticated in the first stage, and operated 



LATERAL SINUS THROMBOSIS 813 

at once, nearly all cases recover. If diagnosticated and promptly oper- 
ated in the second stage, before metastatic extension to the brain, lungs, 
bowels, spleen, etc., fully 50 per cent, will recover; whereas, if diag- 
nosticated and operated in the third stage, the mortality rate is very high. 

In view of the foregoing facts, it is evident that all cases of suppurative 
otitis media, especially if there is a secondary acute manifestation, 
should be critically studied to detect the earliest sign of sinus involve- 
ment. Such observations cannot be made unless the patient is placed 
in bed, with a trained nurse in attendance, and the temperature, pulse, 
and respirations recorded every three hours. Inquiry as to the presence 
of a unilateral headache, not necessarily severe, should be made two 
or three times daily. The surgeon should examine for tenderness over 
the mastoid emissary vein and the posterior triangle of the neck. The 
occurrence of a rigor, even if slight, should excite suspicion, and lead to 
most careful inquiry as to all the other symptoms. 

If a diagnosis is not positively made before a mastoid operation is per- 
formed, the sigmoid portion of the sinus should be exposed and its mem- 
branous wall examined. Infective perisinus abscess may be present, 
without involvement of the intima of the sinus. Sometimes the external 
surface of the membranous sinus is velvety and granular in appearance, 
the smooth surface and pearly gray color normal to the sinus being 
absent. I have seen cases like this recover after exposing the mem- 
branous sinus. They recovered because the intima (lining) of the sinus 
was not yet involved. The drainage of the perisinus abscess checked the 
inward extension of the infective process, and thus thwarted the forma- 
tion of a thrombus in the sinus. 

In one case, observed by the author, in which perisinus abscess was 
present and the lumen of the sinus open, there afterward developed 
thrombosis of the lateral and the cavernous sinuses. The question as to 
the advisability of opening such a sinus is of considerable importance. 
The author believes it should be done, and done thoroughly, the sinus 
being walled off after exploration and packed with iodoform gauze. 

A partial thrombosis of the sigmoid sinus may sometimes be demon- 
strated by compressing the sinus with the finger and noting the uneven 
or nodular surface when collapsed. The use of a hypodermic needle is 
useless for diagnostic purposes, as it may penetrate beyond the thrombus, 
and withdraw blood from the normal blood current. 

In complete thrombosis of the sinus, palpation with the finger gives 
the sense of a doughy resistance. After full exposure of the sinus, it 
should be palpated to determine, as far as possible, the probable extent 
of the thrombus. If it is doughy over the full area of the exposure, the 
clot probably extends to or above the knee, and below to the jugular bulb. 

The knowledge thus gained may determine the advisability of a still 
further exposure of the jugular bulb. (See Thrombosis of the Jugular 
Bulb.) In complete thrombosis there is no flow of blood upon incising 
the sinus, nor will the hypodermic needle draw fresh blood. 

The Diagnostic Value of Blood Cultures in Otitic Disease, Espe- 
cially in Sinus Thrombosis.— In articles first published by E. Libman, 



814 THE EAR 

and later by Libman and Celler, and still later by Seymour Oppen- 
heimer, the conclusions are reached that from the number of cases 
which have been studied as regards the phenomena of bacteremia 
in relative otitic suppuration, it can be definitely stated, that (a) the 
findings of bacteriemia in the presence of a suppurative disease of the 
middle ear and its adjoining osseous spaces is proof evident that there 
is an infective thrombosis of the sigmoid sinus, and such a finding is 
warrant for immediate operation, (b) Furthermore, that if, following 
the sinus operation, streptococci are found in the blood after the first 
day, it indicates that the internal jugular vein is also involved in the 
thrombosis and measures for its operative relief should be at once 
carried out. 

If Oppenheimer's conclusions are sustained by further observations 
and clinical experience, we will have at our command a means for the 
early diagnosis of sinus thrombosis that has hitherto been denied us. 
An early diagnosis before characteristic symptoms appear will enable the 
otologists to carry out surgical measures that will avert great dangers 
to this class of patients. As he so well states, the great problem of sinus 
thrombosis is not so much the etiology or the operative technique, but 
the early recognition of infection of the sinus, as the danger increases 
greatly as each day passes. 

Unfortunately, thrombosis of the lateral sinus (the sinus nearest the 
antrum and cells, and in consequence most often infected) is not always 
characterized by distinct and well-defined symptoms. Symptoms 
such as chills, high fever, sweats, rapid pulse, etc., followed by a rapid 
recession of the temperature to or below normal are not always pre- 
sent, especially when the infection is of the streptococcus type and there 
is a significant differential blood count. In some cases the chill is not 
well marked, and might escape the attention of the surgeon, unless a 
very careful watch of the patient is maintained, which might elicit the 
fact that the patient experienced slightly creepy or chilly sensations. 
Sweating may or may not follow these minor chills. These chilly sensa- 
tions may be complained of especially following the mastoid operation, 
and they are symptoms of the greatest importance, particularly if the 
case is of a typical type. 

Oppenheimer also calls attention to the fact that it has been considered 
in many cases that a blood count, especially an increase in the poly- 
nuclear percentage to over eighty, indicates the presence of a focus of pus 
from which the general circulation is being infected, and in many typical 
cases this is essentially true, and such a count is of value in arriving at 
a diagnosis. In many cases, however, the blood count is of little or no 
value in interpreting the condition present, as the polynuclear per- 
centage may be high and yet no sinus disease exist, or the reverse may 
be the case. 

It appears, therefore, that many cases of sinus thrombosis do not 
present clear and well-defined symptoms, and that the disease often 
progresses to a dangerous stage before the physician suspects its pre- 
sence, and even though operative measures are adopted, the mortality 



LATERAL SINUS THROMBOSIS 815 

rate is extremely high. If, however, as Oppenheimer leads us to hope, 
the use of blood cultures in estimating the bacteremia present will enable 
the otologist to make an early diagnosis, many lives will be saved. 

Oppenheimer cites the investigations of Leutert, Lehart, Neurenberg, 
Kobrakj and Hasslauer as showing that an early and accurate diagnostic 
sign of sinus thrombosis may be elicited by means of blood cultures, 
to estimate the bacteriemia present. With this aid, the otologist could 
by an early operation, before the general system became the seat of 
serious pyemic infection, avert a fatal issue. 

The investigations thus far show (with the exception of that done by 
Duel and Wright) (a) that bacteriemia has not been demonstrated 
in simple otitis media, simple mastoid disease, extradural abscess, or 
in brain abscess; and (b) positive cultures have been demonstrated in 
meningitis and sinus thrombosis. The earlier the culture is taken the 
more often and positive will the results be. 

Duel and Wright have not corroborated the findings of the other 
observers, as they also found bacteriemia in disease of otitic origin, other 
than meningitis and sinus thrombosis. All other investigators, as re- 
ported by Oppenheimer (including himself), have found bacteriemia to 
be a reliable sign of sinus thrombosis, provided other foci of infection, 
as meningitis, endocarditis, phlegmonous pharyngitis, etc., are excluded. 

The differences in the findings of Duel and Wright, and Libman and 
Oppenheimer may perhaps find explanation when the experimental 
work of Stenger is taken into account. The necessity of preventing 
the interpretation of a finding of "primary bacteriemia" — a condition 
common to most systemic pyogenic invasions — and the really significant 
"secondary bacteriemia" must be borne in mind. 

As the technique of blood cultures for determining bacteriemia is a 
technical laboratory process, I will not describe it. I will only state 
(a) that blood or fluid should be withdrawn from the lateral sinus at 
the time of the mastoid operation, also (b) 15 c.c. of blood from a 
peripheral vein of the arm, and both submitted to a laboratory expert 
for cultural purposes. 

If an infective thrombosis is in the sinus, numerous colonies of strep- 
tococci will be found in the cultures from the sinus, while they will not 
be so numerous in the cultures from the blood withdrawn from the 
peripheral vein. 

If in a suspected case of sinus thrombosis the first culture is negative, 
new blood should be withdrawn the next day for another culture, when 
the result may be found positive. A thrombus may be present and the 
needle fail to reach it at the first attempt, or it may be localized at a 
point not reached by the needle, or the general system may not as yet 
be invaded. So long as suspicious symptoms continue after operation, 
make daily cultures until a positive result is obtained or the patient's 
condition improves. 

In the event of a positive result, open the sinus and evacuate its con- 
tents. If the operation upon the sinus is extensive enough, the bacteri- 
emia as shown by the culture of blood from the peripheral vein will 



816 



THE EAR 



rapidly progress toward sterility. If, however, after the lapse of three or 
four days the blood is still bacteriemic, it signifies infective thrombosis 
of the jugular vein (a focus unreached by the sinus operation), and it 
should be resected at once. If, after this, the blood cultures from the 
peripheral vein continue to show bacteriemia, metastatic culture foci are 
present elsewhere in the body, and they should be sought for and elimi- 
nated if possible. (For treatment, see Surgery of the Temporal Bone, 
Chapter XLVIII, and Vaccine Therapy at close of Chapter X.) 

Prognosis. — The prognosis depends chiefly upon the stage in which 
diagnosis and operative procedures are made. If made in the first 
stage, nearly all will recover. If in the second, about one-half will 
recover. If in the third, the mortality rate is high. If not operated, 
nearly all cases terminate fatally. 

Fig. 426 




One of the author's cases of cavernous sinus thrombosis of otitic origin. The drawing shows the 
case in the early stage before thrombus had extended to the left side through the circular sinus. 

Here is a field in which an early diagnosis and an early operation are 
the means of saving life; whereas a late diagnosis, even with operative 
interference, will in a majority of subjects result in death. 

Thrombosis of the Jugular Bulb.— Whiting has formulated the follow- 
ing test: Compress the membranous sinus as near the bulb as possible, 



LATERAL SINUS THROMBOSIS 817 

and draw the finger upward to empty it; the compression is then 
removed, and if the vessel fills from below, it is assumed that the bulb 
is not thrombosed. Allport believes this procedure is dangerous, as it 
may liberate infective clots and disseminate the infection to other parts 
of the body. Such occurrences have not been reported. 

Grunert exposes the jugular bulb by opening the mastoid, exposing 
the sinus, and ligating the jugular. The retro-auricular and cervical 
(jugular) incisions are then united and the tip of the mastoid process 
is resected. The soft parts are then pulled forward and loosened as 
far as the jugular foramen. The bone should be removed until the 
jugular bulb is exposed. (See Surgery of the Temporal Bone.) 

Cavernous Sinus Thrombosis. — Thrombosis of the cavernous sinuses 
is rare. Two cases of otitic origin and one from an abscessed tooth have 
occurred in the author's practice, though this is probably an exceptional 
experience, as many aurists of equally large experience have reported no 
cases. 

When of otitic origin, it usually extends from the superior or inferior 
petrosal sinus to the cavernous sinus. When it complicates inflam- 
mation of the nasal accessory sinuses, it extends from the secondarily 
infected eye through the ophthalmic vein to the cavernous sinuses. 

The general symptoms are similar to those present in thrombosis of 
the lateral sinus. The characteristic symptoms are the marked edema 
of the peri-ocular tissues and the protrusion of the eyeball, as shown in 
Fig. 426, which illustrates one of the three cases just mentioned. 

The first case occurred in a girl, aged twelve years, seven years after 
an attack of scarlet fever, at which time she had an acute otitis media 
purulenta. During the interim (except the last week of her life) she 
was said to have had no ear discharge. The mastoid symptoms and 
otorrhea developed rapidly. When the author saw her on the third day 
she was greatly prostrated and septic, one eye slightly protruding. The 
first chill and rigor occurred on the fourth day. The lateral sinus was 
exposed, but was apparently not thrombosed. Death occurred three 
days later. 

In the second case, a young woman, the cavernous sinus was throm- 
bosed secondarily to the lateral sinus. The lateral sinus was exposed, and 
the thrombus removed as high and as low as possible without estab- 
lishing a flow of blood. The patient gradually became stupid, finally 
comatose, and died one week after the lateral sinus was exenterated. 

The third case occurred in Mrs. W., aged thirty-three years, who for 
four weeks had suffered from an abscessed wisdom tooth on the right 
side. Upon examination the nasal accessory sinuses and the ears were 
normal. The right eyeball protruded, as in Fig. 426. Two days 
prior to the time I saw her the temperature remained steadily at 101° 
F. The next day it remained at 102° F. And on the next, the day I 
saw her, it stood at 103° F. She complained of slight chilly sensations, 
but of no distinct chill. There were no remissions in the temperature. 

The edema of the tissues of the orbital cavity was so characteristic 
that I unhesitatingly pronounced the disease to be thrombosis of the 
52 



818 THE EAR 

cavernous sinus, though the attending rhinologist had made a tentative 
diagnosis of ethmoidal and sphenoidal empyema in spite of the absence 
of suppuration. The family physician had diagnosticated typhoid fever. 
Two days later the postmortem examination corroborated my diagnosis 
of cavernous sinus thrombosis. 

Symptoms. — The symptoms depend on whether one or both sinuses are 
affected. It usually begins in one and spreads to the other through the 
circular sinus. The symptoms shift from one eye to the other, a differ- 
ential point between thrombosis of the cavernous sinus and inflam- 
mations confined to the orbital cavity. 

(a) Pain may be occipital, supra- and infra-orbital, and in the vertex. 

(b) Exophthalmos and edema of the eyelids and side of the nose are 
characteristic symptoms due to venous obstruction. 

(c) Drooping of the eyelids (ptosis), strabismus, and pupillary reac- 
tions due to pressure on the third nerve are also present. 

(d) Edema of the pharynx and tonsil on the same side is occasionally 
present. 

The nerves involved are the second, third, fourth, and sixth, and the 
first division of the fifth. The third is the most constantly involved, 
as is evidenced by the ptosis. The duration of the disease varies from 
a few days to several months, generally only a few days. The death rate 
is extremely high. 

Treatment. — The treatment is chiefly palliative. When tension of the 
conjunctiva is extreme, it may be slit or punctured. The eyeball may be 
removed, together with the thrombosed vessels, with a view of affording 
some relief from the pain and distress. Such interference should be 
undertaken only in extreme cases, as there is no hope of effecting a cure 
by this procedure. Attempts to operate upon the sinus have generally 
failed, though favorable reports have been made. (See Surgery of the 
Temporal Bone.) 



PLATE XVIII 




Base of the Skull: Left Labyrinth Exposed on the Right 
Side, the Grooves in the Base of the Skull are Shown, also 
the Sinuses of the Dura Mater. Two-thirds Lifesize. (After 
Bruhl-Politzer.) 



1, crista frontalis (on the left, beginning of the superior longitudinal sinus) ; 2, foramen cecum (emis- 
sarium Santorini) ; 3, crista galli; 4, lamina cribrosa (olfactory nerve) ; 5, lesser wing of sphenoid; 6, optic 
foramen (optic nerve, ophthalmic artery); 7, anterior clinoid process; 8, sella turcica, flanked by the 
median clinoid process; 9, dorsum ephippii, with posterior clinoid process; 10, foramen rotundum 
(second division of fifth nerve) ; 11, foramen ovale (third division of fifth nerve) ; 12, foramen spinosum 
(middle meningeal artery and recurrent branch of fifth nerve) ; 13, carotid canal and foramen lacerum 
anterius (great and lesser superficial petrosal nerves, Eustachian tube, and tensor tympani muscles) ; 
14, anterosuperior surface of pyramid; 15, cochlea; 16, semicircular canals; 17, tegmen tympani and 
roof of antrum laid open; 18, anterior condyloid foramen (twelfth nerve); 19, posterior condyloid 
foramen (emissarium Santorini) ; 20, foramen magnum; 21, superior petrosal sinus; 22, sigmoid sinus 
(descending portion) ; 23, lateral sinus (horizontal portion) ; 24, superior longitudinal sinus and torcular 
Herophili (confluence of the sinuses); 25, occipital sinus; 26, occipital sinus; 27, vein of aquaeductus 
vestibuli (emerging at the external aperture of aquaeductus vestibuli); 28, internal auditory vein 
(emerging from the internal auditory meatus) ; 29, vein of aquaeductus cochleae (emerging at the external 
aperture of aquaeductus cochleae); 30, inferior petrosal sinus draining the cavernous sinus; 31, 
circular sinus (Ridley) ; 32, groove traversing anterior fossa of skull; 33, sinus of lesser wing of sphenoid: 
34, groove of meningeal artery; 35, transverse groove through middle fossa of the skull; 36. longi- 
tudinal groove through petrous portion of temporal bone (tegmen tympani) ; 37, groove through apex 
of pyramid; 38, transverse fissure (between posterior condyloid foramen and foramen magnum); 39, 
longitudinal groove through posterior fossa of skull; 40, impressio carotica (corresponding to the bend 
in the internal carotid artery); 41, juga cerebralia and impressiones digitatse. 



CHAPTER XLVIII 

SURGERY OF THE TEMPORAL BONE 

Treatment of the surgical diseases and complications included 
in this chapter are: (1) acute mastoiditis; (2) chronic mastoiditis; (3) 
Bezold's mastoiditis; (4) necrosis of the semicircular canals; (5) necrosis 
and suppuration of the semicircular canals and vestibules; (6) necrosis 
and infection of the cochlea and semicircular canals; (7) thrombosis of 
the lateral sinus; (8) thrombosis of the jugular vein; (9) thrombosis 
of the jugular bulb; (10) extradural abscess in the middle fossa of the 
skull; (11) serous meningitis; (12) abscess of the cerebrum; (13) abscess 
of the cerebellum; (14) facial paralysis; and (15) postauricular fistula. 

Ossiculectomy. — The removal of the malleus and the incus for the 
relief and cure of chronic suppurative otitis media has fallen into disuse 
since Macewen's work on The Pyogenic Diseases of the Brain and Spinal 
Cord appeared in 1893. His presentation of the efficacy of the radical 
mastoid operation for this purpose was so convincing that it has been 
almost universally adopted by otologists throughout the world. There 
is now a reactionary tendency to differentiate the cases, and to adopt 
various surgical procedures, according to the characteristics of each case. 
In some instances the radical mastoid operation is elected as the best 
method of procedure; in others, the meatomastoid operation is preferred; 
and in still others, the otologist is content to remove the granulation 
tissue and secretions through the external meatus by means of small 
curettes, the syringe (Figs. 427 and 428), and inflation and irrigation 
through the Eustachian tube by means of a Weber-Liel catheter. 

Technique. — The Anesthetic. — Ossiculectomy may be performed under 
local anesthesia, though it is usually quite painful. In the author's 
experience the most reliable anesthetic mixture is composed of equal 
parts of cocaine, carbolic acid, and menthol. Instil a few drops of this 
mixture into the meatus, and at the end of twenty minutes its full 
anesthetic effect is obtained. 

It is usually preferable, however, to administer a general anesthetic, 
as this insures a painless operation. 

Preparation of the Ear. — The auricle and external meatus should be 
scrubbed with soap and water, followed by an alcohol bath. A cotton- 
wound toothpick or applicator may be used for the purpose. If a general 
anesthetic is to be given, the patient should be placed in a hospital the 
day before the operation, and the bowels and diet regulated as for the 
mastoid operation. 

Incision of the Memhrana Tympani. — The incision may begin at the 
margin, at the junction of the anteroinferior and the anterosuperior 

(819) 



820 



THE EAR 



quadrants of the membrane (Fig. 429), and be extended upward to the 
malleus, thence downward along the anterior border of the handle to its 



Fig. 427 




n* 



Irrigation of the attic through a perforation in the membrana flaccida. 



umbo, or lower extremity, thence 
upward along its posterior border to 
the upper limit of the membrane, 
and thence downward along the 
posterior margin of the membrane 
to the junction of the postsuperior 
and postinferior quadrants of the 
membrane, as shown in Fig. 429. 
This incision makes two flaps of 
the membrana tympani, which drop 
downward and expose the tympanic 
cavity (Fig. 429). This operation 
preserves a large portion of the 
membrana tympani and favors 
speedy regeneration in the process 
of repair. The great objection to 
it is that the lower half of the 
membrane interferes with the drain- 
age of the tympanic cavity. 

Instead of the above incision, the 
entire membrane, or the fragments 
of it, if it is largely destroyed, may 
be removed by making an incision 
around its entire margin and along both borders of the handle of the 
malleus. This provides for drainage during the after-treatment. 




1, the attic; 2, suspensory ligament of the 
malleus; 3, external space of the attic; 4, 
Prussack's space; 5, malleus; 6, external 
meatus; 7, incus; 8, ligament attaching mal- 
leus to inner wall of the tympanic cavity; 9, 
stapes; 10, promontory; 11, cavum tympani. 



SURGERY OF THE TEMPORAL BONE 



821 



Removal of the Malleus and Incus. — The malleus should first be re- 
moved and then the incus. The attachments of the tensor tympani 
muscle and the tendinous attachments of the malleus to the tympanic 
wall should be severed. Various instruments have been devised for this 
purpose, the best of which are Sexton's small angular blades (Fig. 431), 
which should be passed behind the handle of the malleus and carried 



Fig. 429 



Fig. 430 




The right membrana tympani with a per- 
foration at the margin of the postsuperior 
quadrant over the lenticular process of the 
incus, indicating necrosis of the incus and of 
the mastoid antrum. The line a & is the 
line of incision preliminary to the removal 
of the malleus and incus. The flaps of 
membrane thus made drop down and expose 
the upper half of the tympanic cavity to 
view (Fig. 430). 




The incision and flaps preliminary to ossicu- 
lectomy. 1, perforation in the membrana 
flaccida; 2, stapes in the oval window; 3, tym- 
panic orifice of the Eustachian tube; a a, the 
membrana tympani — flaps turned downward. 



upward to the tendinous attachment of the tensor tympani muscle. It 
should then be introduced through the space occupied by the membrana 
(pars) flaccida, to sever the ligamentous attachment to the outer wall of 
the tympanic cavity. 

Delstanche's ring knife (Fig. 432) may also be used to remove the 
malleus. Its ring blade should be insinuated around the handle of the 



Fig. 431 



Fig. 432 



F.A.HABDY&CO. 



Sexton's ossiculectomy knives. 




Ring currettes for removing the malleus. 



malleus and passed upward as far as possible, cutting the attachment 
of the tensor tympani muscle. 

Having thus severed some of the attachments of the malleus, it should 
be removed either with the ring knife or with forceps (Fig. 433). 

The ring knife, or dull ring, should encircle the handle of the malleus 
as high as possible, and then, with a rocking or side-to-side motion. 



822 



THE EAR 



combined with a downward pull, the malleus is dislodged and removed 
through the external meatus. 



Fig. 433 




Showing the severance of the ligamentous attachments of the malleus. After this is done the 
malleus is grasped with the forceps or a ring curette, and drawn downward until its head is dis- 
engaged from the attic. It is then removed through the external auditory meatus. 

Fig. 434 




Removal of the incus with the incus hook, after the removal of the malleus. The hook should 
be introduced posterior to the incus, the incus pushed forward and downward. If it is pushed 
backward it is apt to become lodged in the aditus ad antrum. 



ACUTE PRIMARY MASTOIDITIS 823 

If the forceps are used, the handle of the malleus should be seized 
as high as possible and removed in the same manner as with the ring 
knife (Fig. 433). 

The incus is not so easily dislodged from its position, as its long process 
is often beyond the grasp of the forceps, and even when it can be seized 
it is so fragile that it is apt to break. The incus hook (Fig. 434) is the 
best instrument for its removal. Another difficulty encountered is the 
liability to dislocate it backward into the aditus ad antrum. To obviate 
this mishap, the incus hook should be introduced behind the body of 
the incus and passed upward and forward over its body. The hook 
should then be pressed downward and slightly forward, thus dislodging 
the incus and bringing it into the lower portion of the tympanic cavity, 
where it may be removed with the forceps. 

The stapes is never removed in the operation, as to do so would subject 
the labyrinth to infection and would cause pronounced deafness. 

Hemorrhage. — Bleeding may be controlled by mopping the tympanic 
cavity with adrenalin or with a hot 1 to 2000 bichloride of mercury 
solution. 

Dressings and After-treatment. — The best dressing is a loosely applied 
strip of sterile gauze extending from the tympanic cavity to the auricle. 
The cavity of the auricle should be loosely filled with gauze and cotton 
and the whole covered with an ethereal solution of collodion, which holds 
in place as effectually as a large and cumbersome bandage. 

The after-treatment consists in applying similar dressings and the 
cleansing of the tympanic cavity with cotton-wound applicators, infla- 
tion through the Eustachian tube, and the reduction of granulations 
with carbolic acid or dehydrated crystals of chromic acid, for a period 
of about one month, or until the ear is dry. 

If the operation is unsuccessful, either the radical or the meatomastoid 
operation may be performed. The percentage of cures (chronic otitis 
media purulenta) is very small. 



ACUTE PRIMARY MASTOIDITIS 

Indications for Surgical Intervention.— It is taken for granted 
that the usual abortive therapeutic measures, as (a) the application of 
leeches (or the artificial leech) over the mastoid process and in front of 
the tragus, (b) the instillation of a 12 per cent, solution of carbolic acid 
in glycerin into the auditory meatus, (c) free incision of the membrana 
tympani, (d) ice over the mastoid process, (e) heat, cathartics, etc., have 
been used without success. 

1. These and perhaps other therapeutic measures having failed to 
abort the infectious and destructive process in the cavum tympani and 
mastoid antrum and cells, the disease tends to become chronic, a fact 
which may constitute a sufficient reason for performing a simple exen- 
teration of the mastoid antrum and cells. To wait for other and more 
definite indications might develop the necessity for a much more radical 



824 THE EAR 

operation, or even lead to serious intracranial complications, and en- 
danger the life of the patient. Intervention, when threatened chronicity 
is imminent, requires a comparatively simple surgical procedure, which 
almost always results in a permanent cure, often with but little or no 
impairment of the functions of the ear. 

2. Bulging or sagging of the posterior superior wall of the external 
auditory meatus near the membrana tympani is due to the involvement 
of the mastoid cells below and anterior to the antrum (cells of Kirchner), 
and is a positive indication for the mastoid operation. 

3. Pain over the mastoid antrum and tip which is not relieved by the 
application of ice (one to four hours), alternated with heat, over a period 
of from twenty-four to forty-eight hours, is an indication for the simple 
mastoid operation. The pain signifies congestion, edema, or granula- 
tions which block the drainage of the secretions. Pressure necrosis 
and toxemia rapidly develop under such conditions, and if the pain 
persists, the mastoid antrum and cells should be opened. 

4. Edema and redness of the mastoid region signify blocking of the 
secretions, and, if the condition is not relieved by leeching, ice, heat, etc., 
constitute another indication for surgical intervention. 

5. The presence of a subperiosteal abscess over the mastoid process, 
especially in adults, having its origin through a fistulous opening in the 
mastoid cortex, is an indication for the operation. In infants and chil- 
dren such a condition often has its origin beneath the periosteum of the 
meatus, the mastoid cortex being intact, hence a subperiosteal abscess 
and the infection of the ear and mastoid antrum may be cured by an 
incision (Wilde's) through the skin over the mastoid process. 

6. Meningeal irritation (complicating acute mastoiditis), as evidenced 
by convulsions (in infants and children), delirium, intense headache, etc., 
may call for the mastoid operation. 

7. Other and more -serious intracranial complications, as circum- 
scribed meningitis (epidural abscess), serous meningitis, thrombosis of 
the lateral sinus, etc., constitute positive indications for the mastoid 
operation. 

The Simple Mastoid Operation in Acute Mastoiditis. — The Tech- 
nique. — The preparation of the patient and anesthesia will not be dis- 
cussed farther than to say that the head should be shaved, scrubbed, 
etc., over an area extending at least three inches from the attachment of 
the auricle, both above and behind it. Otherwise the patient should be 
prepared and anesthetized as for any other major surgical operation. 

The incision back of the auricle should be so extended as to fully 
expose the entire field of the operation. In adults, the primary incision 
(Fig. 435, a, a f ) should begin at the mastoid tip one-half inch posterior to 
the attachment of the lobule of the auricle, and extend upward behind 
the auricle, gradually approaching its attachment, until, when near the 
superior attachment, it should be about one-fourth of an inch posterior 
to it. It should then be extended anteriorly to a point immediately 
above the superior attachment of the auricle (Fig. 435, a). If upon 
retracting the posterior flap the operative field (posteriorly) is not fully 



ACUTE PRIMARY MASTOIDITIS 825 

exposed, a secondary incision (Fig. 435, b, b') should be made at right 
angles to the primary one. It should begin on a level with the external 
auditory meatus and be extended backward for a distance of one inch 
(Whiting). In those cases in which the mastoid cells extend well back 
toward the occiput, it will be necessary to extend the secondary incision 
accordingly. 

The primary incision (Fig. 435 a, a') should be first superficially out- 
lined with the scalpel to ensure clean-cut edges, proper curve, and 
extension. It should then be carried through the entire substance of 
the skin, subcutaneous tissue, and the periosteum. 




The postauricular mastoid incision, a, a! , the primary incision; b, b f , the secondary incision. 

The Elevation of the Cutaneous Periosteal Flaps. — The skin and peri- 
osteum should be elevated together. Great care should be taken to 
preserve the periosteum, as the subsequent repair of the wound will de- 
pend somewhat upon the integrity of this structure. With this object in 
view, the author devised the periosteal elevator shown in Fig. 436. The 
periosteal blades are at right angles to the axis of the handle of the instru- 
ment. Experience has shown that this angle is best adapted to the clean 
elevation of the mastoid periosteum. The instrument is provided with 
two right-angle elevators, one elevating on the pull, and the other on 
the push. But little difficulty will be experienced in elevating the upper 
two-thirds of the anterior and posterior flaps; whereas, the lower third 
will be elevated with difficulty, as the tendinous fibers of the sterno- 



826 



THE EAR 



mastoid muscle pierce it. The tendinous bands of this muscle should 
be cut with short, blunt scissors from the external cortex of the mastoid 
tip before elevation of the periosteum is attempted. If this is not done, 
long muscle fibers may be pulled from the stenomastoid muscle, thus 
opening avenues of infection in its substance (Whiting). 



Fig. 436 




The author's mastoid periosteal elevator 
Fig. 437 




The anatomical landmarks for opening the mastoid antrum. The suprameatal triangle, 
the spine of Henle, and sieve-like depression. 

The Anatomical Landmarks. — Having elevated the cutaneoperiosteal 
flaps, the external characteristics of the mastoid process and auditory 
meatus should be noted. To experienced surgeons, this requires but 
a few seconds of time. The first concern should be to determine the 
location of the mastoid antrum, as it forms the deeper landmark of the 



ACUTE PRIMARY MASTOIDITIS 



827 



mastoid process. It is usually located at a depth of about one-half inch 
beneath the mastoid cortex and a little above and behind the cavum tym- 
pani. There are four more or less constant external landmarks which 
will guide the surgeon to the mastoid antrum. The one most constantly 
present is the area of sieve-like perforations in the mastoid cortex just 
behind the external opening of the meatus (Fig. 437). These small 
openings contain minute vessels which bleed after the periosteum is 
elevated. The surface of the bone should be mopped dry, and in a 
moment the bleeding-points will appear. Another landmark usually 
present is the suprameatal spine, or the spine of Henle (Fig. 437). It is 
a small triangle or diamond-shaped bony lip projecting outward and 
forward from the posterior margin of the external auditory meatus. 
The point for entering the antrum is immediately behind the spine. 
The third landmark for locating the mastoid antrum is the suprameatal 
triangle (Fig. 437). The upper boundary of the triangle is formed by 
the lower border of the posterior ridge or root of the zygomatic process; 
the posterior inferior boundary is formed by an imaginary line extending 
from the posterior end of the root of the zygoma to the inferior portion 



Fig. 438 




The Russian perforator. 



of the spine of Henle, or, if this is not present, to the posterior inferior 
margin of the auditory meatus. An opening made in the anterior por- 
tion of this triangle near the auditory meatus will enter the mastoid 
antrum. The fourth landmark to the antrum is the direction of the 
posterior superior wall of the bony portion of the auditory meatus. This 
is ascertained by introducing a straight probe into the meatus along its 
posterior superior aspect and noting the angle of inclination in relation to 
the general surface of the mastoid cortex. Having noted the foregoing 
anatomical landmarks, the exenteration to expose the antrum should 
be begun at the point indicated by the first three landmarks described 
and extended inward in a direction parallel with the probe, as sug- 
gested in the description of the fourth landmark. The usual direction 
of the posterior superior wall of the bony meatus is markedly inward, 
and slightly downward and forward. After excavating for a depth of 
one-half inch (sometimes more, rarely less), the outer extension of the 
mastoid antrum may be looked for. The sigmoid sinus is sometimes 
near the surface. Should the mastoid cortex be carious, the fistulous 
tract may be followed to its origin in the antrum or cells without 
regard to the external landmarks. 



828 



THE EAR 



Opening the Mastoid Antrum.— The Russian perforator (Fig. 438) 
or a gouge may be used to expose the mastoid antrum. If the Russian 
perforator is used, its tip should be placed in the suprameatal triangle 
(Fig. 437), with the long axis of the instrument parallel with the probe 
placed against the posterior superior wall of the meatus, as described 
under External Landmarks. The mastoid cortex is then perforated 
with a boring movement of the perforator, the bone shavings passing 
into the hollow chamber of the instrument. The instrument should 
be removed from time to time to examine the bottom of the bony 
wound, to see when a pneumatic space is uncovered. When this 
occurs, a dark spot will be found in the bottom of the wound. When 
the mastoid cortex is carious the tissue may be excavated with a curette, 
the anatomical landmarks being disregarded. A curved silver probe 



Fig. 439 




Allport's mastoid mallet. 

should be introduced into the pneumatic space, the curved tip being 
directed anteriorly. If the pneumatic space is the mastoid antrum, the 
tip of the probe will pass forward through the aditus ad antrum into the 
cavum tympani, as shown in Fig. 440. If the pneumatic space is a 
mastoid cell, the probe will not pass forward through the aditus ad 
antrum. If the sigmoid portion of the lateral sinus is located anteriorly 
against the posterior wall of the auditory meatus, the perforator will 
uncover it, but will not injure its membranous covering. Herein is 
another reason for preferring the Russian perforator to the gouge. 

I no longer use the Russian perforator, though it is a good instrument 
for beginners in otology. I use the Alexander gouges and first remove 
the cortex, and then open the antrum with a Xo. 6 gouge. The mastoid 
cortex is outlined with the No. 14 gouge and mallet, the gouge being 
so directed as to only include the cortex. After the cortex is thus 
separated around its circumference the large chip of bony cortex is 
freed from its attachment to the underlying cells and removed en 
masse. The mastoid cells are then removed with a rongeur forceps, 
or if the bone is soft or necrotic, with a large spoon curette. The antrum 



ACUTE PRIMARY MASTOIDITIS 



829 



is then opened with a No. 6 Alexander gouge, the gouge being directed 
toward the bridge of the nose. 

As "Whiting has so well shown, the external conformation of the mas- 
toid process will show the position of the sigmoid portion of the lateral 
sinus. The sinus, being a large vessel, requires space; hence, the area 
of greatest external bulging or convexity of the mastoid cortex may be 
taken as a guide to the location of the sinus. When the convexity is at 

Fig. 440 




The opening into the mastoid antrum made with the Russian perforator. The fact that the 
silver probe passes forward through the aditus ad antrum into the cavum tympani is proof that 
the pneumatic space at the bottom of the wound is the antrum and not a mastoid cell. 



the middle portion of the mastoid cortex, it is well out of the way in open- 
ing the antrum. When, however, the anterior portion of the mastoid 
cortex is elevated, and the posterior wall of the meatus drops at right 
angles from it, the sinus is located anteriorly, and will be exposed in 
opening the antrum. In such subjects, it may be necessary to open 
the antrum by removing the posterior wall of the meatus after the 
method of Stacke. 

Having exposed the mastoid antrum, its dimensions and extensions 
should be determined with a bent probe introduced through the bony 



830 



THE EAR 



wound. The whole outer wall of the antrum should then be removed 
with a gouge and mallet or the rongeur forceps. 

The Removal of the Mastoid Cortex. — The mastoid cortex may be 
removed in parallel shavings (Fig. 441), as recommended by Whiting. 
From three to four grooves are made, exposing the superficial cells. 
The gouge may be applied at either the mastoid tip, as shown in the 
drawing, or at the level of the mastoid antrum. Care should be exer- 
cised to avoid injuring the mastoid emissary vein shown at the posterior 

Fig. 441 




The remova2 of the cortex of the mastoid process, 



portion of the mastoid process (Fig. 441). This vein opens into the 
sigmoid portion of the lateral sinus, and, when injured, bleeds profusely 
and persistently. It may be readily closed by placing the tip of some 
blunt instrument against the opening of its bony canal and tapping it 
smartly with the mallet. (See preceding paragraph for another method 
of removing the mastoid cortex.) 



ACUTE PRIMARY MASTOIDITIS 



831 



The Exenteration of the Mastoid Cells. — After the cortex is removed 
the cells should be broken down and removed with the curette and the 
rongeur forceps. If the intercellular walls are soft or necrosed, they 
may be removed with a curette. If they are firm, the rongeur forceps is 
better for the purpose. The o\ T erhanging edges of the mastoid cortex 
should be removed with the rongeur forceps (Fig. 442) until all cells are 
completely exposed and accessible to curettement. Large mastoid cells 
are often found in the tip of the process. These may be the focal centre 
of the infection and the only place where pus is found. The cells should 

Fig. 442 




The completion of the removal of the mastoid cortex with the rongeur forceps 
. may also be removed with the same instrument. 



The cells 



therefore be exposed to the tip in all cases, as otherwise the focal centre 
of infection may not be exposed and the operation fail of its purpose. 
All cells should be opened, but not completely obliterated, as the 
mucous membrane is essential to the rapid healing of the wounds. 

The Irrigation of the Wound. — As the infective microorganisms in 
acute mastoiditis are usually quite active and virulent, and it being 



832 



THE EAR 



Fig. 443 



almost impossible to prevent them coming in contact with the soft 
tissues, it is a wise precaution to irrigate the wound with a 1 to 4000 
bichloride solution at about 110° F. The external auditory meatus 
should also be scrubbed and irrigated with the same solution, care 
being exercised to avoid injuring the membrana tympani and dis- 
locating the ossicles. Tincture of iodine may also be applied to the 
wound. 

The Closure of the Cutaneous Wound. — As drainage must be main- 
tained for several days, and the cavum tympani is not exposed by the 
operation, it is necessary to provide for drainage through the posterior 
wound. 1 

The cutaneous wound is not, therefore, completely closed at the time 
of the operation. The upper two-thirds is sutured, as shown in Fig. 443, 

while the remaining lower third is left open 
for the introduction of the drainage tube 
and gauze. 

The Dressing. — The object of the dress- 
ing is twofold— -namely, to promote drain- 
age and protect the wound from further in- 
fection while the process of repair is in pro- 
gress. In order to accomplish the first object, 
the dressing should be so applied as to insure 
free drainage. According to the author's 
experience, only so much gauze should be 
introduced into the depth of the bony wound 
as to carry off the secretions to the outer 
absorbent dressing. To pack the wound 
with gauze is poor practice, as the gauze 
becomes saturated with the secretions, retains 
them in the wound, where they bathe its 
walls and retard the reparative process. On 
the other hand, if only a small wick of gauze 
is carried to the bottom of the bony wound, 
the secretions are carried out as fast as 
formed, and the healing process progresses 
uninterruptedly and rapidly to recovery. A 
spirally cut soft rubber tube, with a small 
wick of gauze placed loosely in its lumen 
(Fig. 444), should be introduced into the 
mastoid wound. A small wick of gauze is also placed in the external 
auditory meatus. The outer absorbent and protective dressing consists of 
gauze pads, 5x6 inches, placed over the auricle and mastoid wound, and 
held in position with a bandage applied in a fan-shaped figure (Fig. 465). 
The bandage should not be applied under the chin or around the neck, 
as it is uncomfortable and unnecessary. 

1 In performing the simple mastoid operation for acute mastoiditis it is unnecessary to expose the 
external auditory meatus, as is shown in the drawings. The drawings are thus made to show 
the anatomical landmarks for teaching purposes, and for reference in describing the radical and the 
meatomastoid operations for chronic mastoiditis. 




Method of closing the mastoid 
incision after the simple mastoid 
operation in acute mastoiditis. 
The spiral rubber tube and gauze 
drain in the lower angle of the 
incision prevent disfigurement. 



CHRONIC MASTOIDITIS 833 

The After-treatment. — The first dressing should be removed at the 
expiration of three days, the wound cavity gently mopped dry with a 
cotton-wound applicator, and another spiral tube dressing introduced. 
The meatus should also be mopped until freed of secretions, a fresh 
gauze wick applied, and the whole covered with gauze pads, as in the 
first dressing. The sutures should be inspected before redressing the 
wound, and if stitch abscesses are present, the sutures should be removed. 

Fig. 444 



• 




A spirally cut rubber tube with a small wick of gauze in its lumen constitutes one of the 
best drainage dressings after mastoid operation. 

If the wound is healthy, they may be left in position until the fourth or 
fifth day. The wound should be dressed daily as described, until the 
secretion diminishes to a small amount, after which the tube should be 
omitted and only a small wick of gauze introduced. The cavity will then 
rapidly fill in from the bottom with healthy granulation tissue, and 
at the end of from three to six weeks be entirely healed, with a slight 
depression at the lower angle of the wound. 

In exceptional cases infection of the labyrinth, sinus thrombosis, etc., 
may develop subsequent to the operation and modify the course of the 
reparative process, or even necessitate the adoption of other surgical 
procedures hereinafter described. 



CHRONIC MASTOIDITIS 

Chronic mastoiditis is one of those diseases which resists simple 
methods of treatment, and for the last fifteen years the radical mastoid 
operation has been the only treatment that insured any real success. 
Two years ago, however, Charles J. Heath, of London, called attention 
to the brilliant results obtained by a less radical procedure, whereby 
the hearing was greatly improved and the disease apparently cured. 
Korner, Stacke, and others previously described an operation somewhat 
similar to that described by Heath. Since then the author has performed 
forty-five operations with a modified technique, with good results. The 
difference between the methods is that the author makes a complete 
exenteration of all the pneumatic cells of the temporal bone and uses 
a modified Ballance plastic meatal flap, as in the radical operation. 
To this new operation he has given the name meatomastoid. The (a) 
radical and the (6) meatomastoid operations will therefore be described 
as remedial measures for the cure of chronic mastoiditis. 

The Radical Mastoid Operation. — Technique. — The Removal of the 
Cortex and the Exenteration of the Mastoid Cells. — The patient is pre- 
pared as for the simple mastoid operation in acute mastoiditis. The 
53 



834 THE EAR 

mastoid antrum and cells are exenterated as in the simple operation in 
acute mastoiditis (see Simple Mastoid Operation, Figs. 440, 441, and 442), 
with this difference : In the simple mastoid operation there is no neces- 
sity for making a complete exenteration; whereas in the radical opera- 
tion all pneumatic spaces in the mastoid process and zygomatic root, 
as well as those in the posterior wall of the pyramid of the petrous portion 
of the temporal bone (Jansen), are removed. It is not enough to ex- 
pose the cells to view, they must be totally exenterated. To fail in this 
respect may lead to the necessity of performing a secondary operation. 
It has been claimed by some operators, who do not completely remove 
these cells, that it was impossible to tell when all of them had been 
removed. They also claim that 25 per cent, of the radical mastoid 
operations had to be followed by secondary operations. While it is 
true that the operator cannot positively state that all the cells have been 
removed, he can at least endeavor to remove them, and in the vast 
majority of cases he will be successful. It has been the author's earnest 
endeavor during a period of ten years to remove all the pneumatic 
cells, whether in the mastoid process, zygomatic root, or in the posterior 
wall of the pyramid, with the result that only 1 per cent, of all cases 
have required a secondary operation. The good results obtained were 
partially due to the painstaking removal of all the pneumatic cells in 
the temporal bone and to certain points of improved technique to be 
narrated in subsequent paragraphs of this chapter. 

The Removal of the Posterior Wall of the Bony Meatus. — Having com- 
pleted the exenteration of the mastoid antrum and cells, the posterior 
wall of the bony meatus is removed with a chisel, as shown in Fig. 445. 
In the removal of this wall there are certain anatomical structures which 
may be injured if due care is not exercised to avoid them. These struc- 
tures are the facial nerve, the external or horizontal semicircular canal 
(Fig. 445, b), and the dura of the middle fossa of the skull (Fig. 445, e). 
The facial nerve emerges from the petrous portion of the temporal bone 
and passes backward along the superior margin of the inner wall of the 
cavum tympani just above the oval window (Fig. 445). It then courses 
downward across the inner and inferior wall of the aditus ad antrum, 
immediately below the upper and deeper portion of the bony wall of the 
meatus (Fig. 445, c). From thence it passes downward, deeply buried in 
the plate of bone forming the posterior wall of the auditory meatus, and 
emerges just posterior to the styloid process. The nerve is most liable to 
injury in removing the deep portion of the posterior meatal wall directly 
over the aditus ad antrum, as it is only protected in this area by a thin 
but dense bony covering. Should the chisel by any mischance cross the 
space of the aditus ad antrum (the channel of communication between 
the cavum tympani and the mastoid antrum) to its inner and inferior 
wall, across which the facial nerve passes, facial paralysis may follow. 
In the removal of the posterior wall of the meatus the more superficial 
parts may be removed without fear of damaging the facial nerve, while 
the deeper portion should be removed with due care to avoid this danger. 

After the facial nerve crosses the floor of the aditus ad antrum it turns 
sharply downward and emerges near the styloid process. As it makes 



CHRONIC MASTOIDITIS 835 

the bend (Fig. 445, c) it rises almost to the level of the posterior portion 
of the annulus tympanicus, to which the membrana tympani is attached. 
It is obvious, therefore, that the lower portion of the posterior wall of the 
meatus cannot be removed deeper than the annulus tympanicus without 
injuring the nerve. 

Fig. 445 




Anatomical landmarks after the complete exenteration of the mastoid process and cavum 
tympani: a, the round window; b, ridge of horizontal, semicircular canal; c, the facial ridge; 
d, the stapes in the oval window; e, the dura of the middle fossa exposed through a perforation 
in the tegmen antri. 

To recapitulate: The upper portion (patient in erect position) of the 
posterior wall of the meatus may be removed in its entirety, or down to 
the aditus ad antrum, whereas the lower portion should only be removed 
down to the level of the annulus tympanicus or posterior segment of the 
drum-head. The complete removal of the wall, insofar as it is com- 
patible with the integrity of the facial nerve, is shown in Fig. 445. In the 
meatomastoid operation the removal does not include the annulus 
tympanicus. When completely removed, the upper bony wound extends 
inward at almost right angles to the lateral plane of the head, whereas the 
inferior bony wound extends inward and upward at an acute angle to 
this same plane. 

£ Another important anatomical structure in the immediate vicinity of 
the facial nerve as it crosses the floor of the aditus ad antrum is the 
external or horizontal semicircular canal (Fig. 445, b). It is located a 
little above and behind, and more superficially, than the facial nerve at 



836 THE EAR 

this point. The precautions taken to avoid injuring the nerve will 
at the same time protect the semicircular canal. Indiscriminate curet- 
tage of the inner wall of the cavum tympani (middle ear) may injure 
either the facial nerve, the semicircular canal, or the stapes and oval 
windows (Fig. 445). 

All these structures should be constantly held in mind during the re- 
moval of the posterior bony wall of the meatus. The dura of the middle 
fossa (Fig. 445, e) is in but slight danger of exposure, and even when 
exposed the probability of infection is slight, as the pathogenic micro- 
organisms of chronic infection are but moderately virulent. One of the 
greatest objections to the radical mastoid operation is that the hearing is 
often impaired, especially after a period of one year. The impairment 
of the hearing is due to two factors, namely : (a) To the displacement of 
the foot-plate of the stapes in the oval window (Fig. 445, b) at the time 
of the operation, and (b) to the gradual displacement and fixation of the 
foot plate of the stapes by cicatrices and contraction subsequent to the 
operation. On the other hand, it is claimed that the radical operation 
is justified, because in many cases it is the only known procedure that 
will cure the chronic otorrhea and protect the patient from the dangers 
incident to such a pathogenic process in the temporal bone. Life in- 
surance companies have justly refused policies to persons affected with 
chronic otorrhea, and have granted them when an aural surgeon of 
repute has made a written statement that they were cured by the radical 
operation. 

^Yith these facts in mind, the radical mastoid operation has been and 
is still a justifiable procedure in properly selected cases. It is impor- 
tant, however, that the surgeon should take every precaution in the per- 
formance of the operation, consistent with safety to the life and health of 
the patient, to preserve the hearing as much as possible. In order to 
do this, the stapes and the oval window must be protected and extrac- 
tion of the stapes from the oval window most carefully avoided. Should 
the latter occur, it opens an avenue of infection to the labyrinth, which 
means the almost certain loss of hearing. Fortunately, infection has 
rarely occurred when this accident has happened in the course of the 
radical operation, as the infective bacteria are usually of low virulency. 

The removal of the posterior bony wall of the meatus converts the 
cavum tympani, mastoid antrum, and the mastoid cells into one large 
irregular cavity (Fig. 445), which is easily drained, and, if the plastic 
surgery of the meatal skin flaps is properly executed, results in a cure 
of the disease in more than 95 per cent, of the cases. 

The Removal of the Malleus and Incus.— The removal of the malleus 
and incus, or their necrotic fragments, is an essential part of the radical 
operation, as it has been held that if they are left in position the attic of 
the middle-ear cavity will not be sufficiently drained. This is true to a 
degree, as the bodies of these bones partially form the floor of the attic, 
and their presence interferes somewhat with the exit of the secretions 
from the attic or upper portion of the cavum tympani. Furthermore, 
the complete removal of the bony partition involves the fracture and 
removal of a portion of the annulus tympanicus, to which the membrana 



CHRONIC MASTOIDITIS 



837 



tympani is attached. In addition to this the incus, the long process of 
which projects backward into a sulcus of the bone forming the wall 
of the aditus ad antrum, would, in many instances, be dislocated and 
thus rendered useless as a functionating mechanism of the ear. 

The technique of the removal of the malleus and incus is comparatively 
simple if the skin incision or incisions have been sufficiently extended 
to allow the complete exposure of the auditory meatus and cavum 
tympani. The primary skin incision (Fig. 435, a, a') should, at its 
upper limit, extend one-half inch anterior to the upper attachment of the 
auricle. This will allow the auricle to be retracted far enough forward 
to expose the meatus and cavum tympani. 



Fig. 446 




The removal of the malleus and incus in the radical mastoid operation. 

When the posterior bony wall of the meatus is removed, the middle- 
ear cavity should be packed with cotton saturated with a 1 to 2000 
solution of adrenalin chloride to check the hemorrhage. After the lapse 
of five minutes it should be removed and the contents of the cavum 
tympani inspected. The manubrium or handle of the malleus should 
then be seized with small alligator forceps, dislocated downward, and 
removed. The incus should be likewise removed. Instead of the 
alligator forceps a small curette may be used, though the danger of 
dislocating and extracting the stapes is thereby increased (Fig. 440). 



838 



THE EAR 




The Removal of the Outer Wall of the Attic and Atrium— The outer 
wall of the attic (superior wall of the external bony meatus) should be 
removed to fully expose the tegmen tympani to inspection and curette- 
ment. This procedure also gives the surgeon direct access to this region 
during the after-treatments. This is accomplished with a chisel or gouge, 
as shown in Fig. 447, a. 

The outer wall of the atrium (inferior wall of the meatus) should also 
be removed. This may be done by curetting the anterior and posterior 

margins of the annulus tympani- 
fig. 447 cus, and chiselling away the 

deeper portion of the floor of 
the external meatus (Fig. 447). 
The failure to observe these points 
of technique may defeat the 
object of the radical operation 
and necessitate the performance 
of a secondary operation. 

The Removal of Necrosed Bone 
from the Cavum Tympani. — Ne- 
crosis of the tegmen tympani 
(roof of the attic) is present in a 
majority of the subjects of chronic 
mastoiditis, a fact which gives 
color to the claim that the radical 
operation should always, or at 
least usually, be performed in 
these cases. This phase of the 
subject will be more fully dis- 
cussed under the meatomastoid operation in chronic mastoiditis. All 
necrosed tissue in the tegmen tympani, or elsewhere in the walls of the 
cavum tympani, should be carefully but thoroughly removed with a 
small, sharp curette. The region of the oval window and the promon- 
tory, as well as the external semicircular canal, should be inspected, under 
adrenalin ischemia, with a strong reflected light for necrosed bone and 
granulation tissue, and, if found, the proper surgical procedures should 
be instituted to improve the conditions of the labyrinth which the necrosis 
and granulations indicate are present. * 

Curettage of the Eustachian Tube. — Many failures attending the 
radical mastoid operation are attributed to the infected and purulent 
discharge from the tympanic end of the Eustachian tube into the cavum 
tympani, subsequent to the operation. With this fact in view, it has 
been recommended that the tympanic end of the tube should be curetted, 
or burred out, to promote its closure by granulation tissue and cicatricial 
contraction (Fig. 448). The author has repeatedly performed this pro- 
cedure, with an almost unbroken record of failures. He attributes the 
failures to the fact that in nearly every instance the suppuration within 
the tube had its origin either in a chronic epipharyngitis or a chronic 
ethmoidal and sphenoidal infection, to which the salpingitis is often 



Schema showing the removal of the outer ws.ll 
of the attic (a) (upper deep wall of the meatus) 
in the radical mastoid operation, to expose the 
attic in the after-treatments. 



CHRONIC MASTOIDITIS 



839 



due. Epipharyngitis may also be caused by the enlargement of the 
posterior ends of the turbinated bodies, and to the presence of adenoids. 
If either of these conditions is present, it should be surgically corrected. 
The failure of the tube to close may also be due to the fact that too large 
a burr was used. To be successful, the burr should be small enough to 
reach to the isthmus of the Eustachian tube. If the sinus disease and 
epipharyngitis are corrected, the curettage of the Eustachian tube would 
almost invariably result in its permanent closure. 



Fig. 448 




Curettage of the tympanic end of the Eustacian tube to cause it to close. A small burr 
or curette should be used to reach the isthmus of the tube. 



Inspection of the Bony Wound. — Having completed the surgery of the 
bone, the wound should be dried with small gauze tampons and the appli- 
cation of adrenalin. Fistula of the external semicircular canal should 
be especially searched for. If present, it is indicated by a small granular 
area just posterior and above the facial ridge in the region of the aditus 
ad antrum. If found it should not be probed or otherwise disturbed, 
as this would break down the wall of granulation tissue deposited there. 
and might give rise to an acute labyrinthine inflammation and cause 
death. If anything is done at all it should be freely opened, as shown 
in the surgery of the labyrinth. As a matter of fact, most of these cases 



840 



THE EAR 



will recover without an operation other than the radical mastoid opera- 
tion, as this establishes free drainage and checks the necrotic process. 

The Plastic Surgery of the Cutaneous Meatus. — The success of the 
radical mastoid operation often largely depends upon the proper use of 
the skin of the auditory meatus in lining the bony cavity of the mastoid 
wound. The bone of the mastoid process is frequently sclerosed, and 
affords scant soil for the formation of granulation tissue with an epider- 
mis covering. The granulation tissue in such subjects is poorly nour- 
ished, as the blood supply from the underlying bone is scant, and infec- 
tion, therefore, often occurs. The reparative process is thus hindered, 
and the after-treatment may be extended over a period of several months. 
This deplorable state of affairs may be largely overcome by the proper 
disposition of the meatal skin flaps against the bony walls of the mastoid 
wound. The plastic flaps thus reflected become adherent to the walls of 
the mastoid wound, and immediately cover a large portion of the bone 
which would otherwise have to depend upon the reparative granu- 
lation tissue, springing from the bone. In addition to this, the full blood 



Fig. 449 




Curved flat scissors. 

supply of the meatal flaps insures the rapid extension of the granulation 
tissue from their edges. The scant blood supply from the sclerotic bone 
of the mastoid process is thus complemented by that of the meatal skin 
flaps, and a speedy regeneration and epidermization of the entire mas- 
toid wound may be confidently expected. In exceptional cases it will be 
necessary to resort to plastic skin flaps from the margins of the mastoid 
wound, or upon Thiersch grafts, as recommended by Charles Ballance. 
(See Thiersch Grafts.) 

The technique of the formation and application of the plastic flaps 
of the meatus to be described is after the method recommended by 
Ballance. The form of the flaps is after Ballance. The suturing to 
hold them in position is, so far as known, original with the author. 

Before making the incision in the meatus all the tissue on the posterior 
surface of the cutaneous meatus should be removed with short, stout, 
curved scissors (Fig. 449). This should be carried to the extent shown 
in Fig. 451, which shows the whole of the meatus and a portion of the 
concha divested of all tissue except the cartilage of the concha. The 



CHRONIC MASTOIDITIS 



841 



skin of the concha is included in the upper plastic flaps. This extensive 
removal of all the tissues, as shown, is essential, because by so denuding 
them the meatal flaps can be more perfectly and extensively applied to 
the bony walls of the mastoid wound. It is obvious that the meatal flaps, 
with the thick, tendinous, fibrous, muscular, and cartilaginous tissues 
attached to them, could not be properly reflected and adapted to the 
walls of the mastoid wound. 

Fig. 450 




Removing the fibrous and muscular tissue from the posterior surface of the cutaneous meatus 
and concha, preparatory to making the plastic meatal flaps. 



Having prepared the meatus and concha as described in the preceding 
paragraphs, and as shown in Fig. 451, the Ballance incision, sometimes 
referred to as the "shepherd's crook" incision, should be made. While 
it is by no means as easy as might be inferred from the schematic draw- 
ings, it is nevertheless comparatively so if the superfluous tissue is 
removed as recommended. The blades of Allport's divulsion forceps 
(Fig. 452) should be introduced into the meatus with the tips at the inner 
end of the meatal tube. They should then be spread, to put the meatal 
tube upon a slight tension, and should be placed so that the open space 
between them is at the posterior inferior segment of the tube, in order 



842 



THE EAR 



that the straight incision may be made through this portion of the meatus, 
while the curved portion is made from the anterior surface of the auricle, 
as shown in Fig. 453. If the cartilage of the conchal portion of the upper 



Fig. 451 




The Ballance incision. The straight portion is made in the posterior inferior portion of the 
meatus, and the curved portion in the concha. The curved portion should be made from the 
anterior aspect of the concha (Fig. 453) . 

flap has not already been removed, it should be done at this time, as it 
will otherwise interfere with the placement and attachment of the flap 
to the bony wall of the mastoid wound. 



Fig. 452 




Showing the method of splitting the posterior wall of the skin meatus with Allport's meatus 
divulsor in position to convert it into flaps for reflecting into the upper and lower portions of the 
mastoid bone cavity. 



Ballance stitches the flaps to the posterior fleshy surface of the 
anterior or auricular mastoid flap. According to the author's method, the 
plastic meatal flaps are anchored to the posterior mastoid flaps, as shown 



CHRONIC MASTOIDITIS 



843 



Fig. 453 



Fig. 454 





The Ballance plastic meatal incision. The 
incision begins in the posterior wall of the 
meatus (straight dotted line) and extends into 
the concha in the form of a shepherd's crook. 



The plastic flaps slightly retracted with the 
anchor sutures in position. 



Fig. 455 




The plastic meatal flaps with the anchor sutures in position. When the auricle is placed in 
its proper position and the anchor stitches are drawn over the rolls of gauze (Figs. 450 and 457) 
the plastic meatal flaps will partially line the mastoid wound. 



844 



THE EAR 



in Figs. 454, 455, and 456. Two sutures are used in the superior meatal 
flap, one in the conchal portion, one in the meatal portion, and but 
one in the abbreviated inferior meatal flap (Fig. 451). One thread of 
each suture is introduced beneath the skin and subcutaneous tissue 
of the posterior mastoid flap for a distance of three-quarters of an inch, 
and then through these tissues to the surface of the skin. The other 
thread of each suture is placed in the primary mastoid incision (Figs. 
454, 455, and 456). Before piercing the mastoid skin with the sutures, 
the auricle and mastoid flaps should be placed in their proper relations. 



Fig. 456 




The postauricular incisions closed and the anchor sutures tied over small rolls of gauze. The 
anchor sutures retract the plastic meatal flaps into the mastoid wound, when they become adhe- 
rent and partially cover the bony surface with true skin. The whole surface is finally covered by 
extension from the borders of the plastic flaps. 



to the head, and traction should be made upon each suture until the 
flaps assume the proper position in the mastoid wound. The conchal 
suture should be thus tested and its location determined. The meatal 
suture of the superior meatal flap should next be tested, and, finally, 
the inferior meatal suture. The flaps should be properly located and 
stitches in the posterior mastoid flap placed accordingly. The ends 
of the sutures should then be secured with artery forceps until the 
mastoid incision is completely closed by sutures. The anchor sutures 
should then be tied over small rolls of gauze (Figs. 456 and 457), be- 
ginning with the upper, and thence to the lower ones, until the flaps 



CHRONIC MASTOIDITIS 



845 



assume the desired positions in the mastoid wound. The upper flap is 
drawn against the roof of the mastoid wound, while the lower is drawn 



Fig. 457 




The drainage dressing consists of a spirally cut soft rubber tube with a small wick of 
gauze in its lumen. 

Fig. 458 




The Siebermann Y-plastic incision of the concha and skin meatus. Three flaps are formed 
by it, an upper and a lower meatal flap and a V-shaped conchal flap. The cartilage should be 

removed from the V-shaped conchal nap, and each should be drawn backward into the mastoid 
Wound by sutures and fixed in position, 



846 



THE EAR 



over the facial bridge. The bony walls being removed, and the cutaneous 
flaps reflected into the mastoid cavity, and permanent free drainage 
and ventilation of the middle ear and mastoid cavities thereby assured, 
the dressings may be applied ma the external auditory meatus, as shown 
in Fig. 457. Other methods of making the plastic meatal flaps are 
shown in Figs. 458 to 463. 



Fig. 459 




Showing the Troutmann tongue flap, which should be reflected into the mastoid wound and held 
in apposition to its posterior surface by small pledgets of gauze packed over cargile membrane. 
Remove the gauze in forty-eight hours. 




Fig. 461 




The Panse plastic incision of the meatal skin. 



The Jansen-Stacke plastic incision. This 
flap should be used when the sigmoid sinus 
and jugular bulb are exposed. The flap is 
turned downward and backward and thus 
covers these areas. 



After-treatment. —The primary dressing is identical with that for 
acute mastoiditis, with the single exception that the spiral tube and 
gauze are inserted through the enlarged meatal opening in the concha 
(Fig. 457) instead of through the postauricular wound. The distal end 
of the tube is placed into the deepest portion of the mastoid wound. 



CHRONIC MASTOIDITIS 



847 



This should be removed on the fifth day, or earlier if the temperature 
persistently remains above 102° F., or if severe pain develops and per- 
sists. The wound should be mopped dry with a cotton- wound appli- 



Fig. 462 





Showing the method of making the Jansen modification of the Stacke plastic flap of the skin 
meatus. The inferior large flap should be reflected into the lower portion of the mastoid wound 
and held in place by anchor stitches. The upper short flap should be reflected into the upper 
portion of the mastoid wound and held in place by an anchor stitch. 



Fig. 463 



Fig. 464 








A collodion dressing used in the after-treat- 
ment of operative mastoiditis. A loose wick 
of gauze is inserted into the mastoid wound 
through the external meatus and covered with 
a film of cotton, which is then saturated with 
an ether solution of collodion to seal it. 



The appearance of the concha and the 
external auditory meatus, after healing is 
complete. 



848 



THE EAR 



Fig. 465 



cator, inspected for exuberant granulations, and a fresh sterilized tube 
and gauze inserted. If exuberant granulations are present, they should 
be reduced by painting them with 95 per cent, carbolic acid, and, after 
the lapse of one minute, with alcohol, to check the action of the acid. 
This method of treatment should be continued daily for ten days after the 
operation. After this the tube may be abandoned and a small wick of 
gauze inserted into the wound at its most dependent portion and extended 
to the concha. Small gauze pads should be placed in the concha of the 
auricle to catch the secretions drawn out by the gauze wick. Large pads 
are placed over the auricle and mastoid region and secured with the fan- 
shaped bandage (Fig. 465). After the tenth day the large gauze pad and 
bandage may be omitted and the dressing applied in the cavity of the 
auricle instead. This should be secured by placing a thin film of cotton 

over it (Fig. 463) and painting it with 
an ethereal solution of collodion (Pierce). 
The mastoid wound usually becomes 
covered with squamous epithelium in 
from three weeks to two months, though 
the process may cover a longer period 
of time. Various factors may cause a 
prolongation of the period of repair, 
chief of which are suppurative inflam- 
mation of the epipharynx, ethmoiditis, 
sphenoiditis, and an infection of the 
Eustachian tube. Certain constitutional 
dyscrasias, as syphilis, tuberculosis, and 
struma, may also lower the vitality of 
the tissues and prolong the reparative 
process. 

The disfigurement following the Bal- 
lance plastic meatal flaps is slight (Fig. 
464). It should be said, however, that 
chondritis of the auricle with marked 
shrinkage and deformity may follow any 
of the plastic operations which include the cartilage of the concha. 
Every effort should be made to prevent the infection of the wound either 
during or after the operation. The edges of the conchal wound should 
be touched with carbolic acid to seal up the lymph spaces. . 

Author's Modified Radical Operation. — This operation may be called 
a modified radical mastoid operation, though it does not include the 
exposure of the middle ear. It does, however, include the plastic 
meatal flaps and the removal of the posterior bony wall of the meatus 
down to the annulus tympanicus. The postauricular wound is closed 
as in the radical operation, and the dressings are applied through the 
conchomeatal wound. 

The advantages claimed for this operation over the radical operation 
in chronic mastoiditis are: (a) The preservation of the function of the 
middle-ear contents, and of the membrana tympani; (b) an improve- 




Method of applying a bandage over the 
ear and mastoid process. 



CHRONIC MASTOIDITIS 849 

ment in the hearing, whereas in the radical operation the hearing is 
either unchanged or impaired; (c) the closure of the perforation in the 
membrana tympani which often takes place after the necrosis and granu- 
lations have disappeared; (rf) the drainage of the secretions from the 
antrum and mastoid cells into the auditory meatus through the opening 
in the posterior wall of the- meatus, thus relieving the Eustachian tube 
of the excess of secretions. 

The principle upon which the operation is based is that if ample 
drainage is provided the infectious process tends to subside and the dis- 
eased tissue to heal. The removal of the posterior wall of the bony 
auditory meatus and the retraction of the plastic meatal skin flaps into 
the mastoid wound provide for the drainage of the mastoid antrum 
and cells, and thus remove the stress from the Eustachian tube. The 
Eustachian tube, being relieved, is usually ample to drain the cavum 
tympani, even when chronically infected. As a result, the resistance 
of the diseased membrane, periosteum, and bone is increased, and the 
infection gradually subsides. The mucous membrane, periosteum, and 
bone become healthy and "heal out." 

The removal of the fragments of the malleus and incus often disturbs 
the relation of the stapes to the fenestra vestibuli (oval window), and 
thus impairs the hearing; that is, the stapedius muscle pulls the stapes 
backward and displaces the foot-plate of the stapes in the window. 
This could be obviated in the radical operation by severing the tendon 
of the stapedius muscle. 

Technique. — (a) Prepare the patient as for the simple and radical 
mastoid operations. Extend the skin incision well forward above the 
auricle as in the radical operation, as this allows the external bony 
meatus and drumhead to be clearly seen during the operation. 

(b) Expose the mastoid antrum and cells as in the radical operation. 

(c) Remove the posterior bony wall of the auditory meatus down to 
the annulus tympanicus, as shown in Fig. 466. At no time during the 
operation should the membrana tympani and the ossicles of the cavum 
tympani be injured by probing or other instrumental procedure. The 
introduction of a probe into the meatus to determine its depth and 
direction, as recommended in the radical operation, should be studiously 
avoided. If this precaution is not observed, the ossicles may be dislocated 
and the hearing impaired. The posterior wall of the meatus should be 
removed as widely as possible to provide free drainage and access to 
the exenterated antrum and cells through the auditory meatus during 
the after-treatment. It is sometimes necessary to remove some bone from 
the outer portion of the superior wall of the meatus to fully expose the 
drumhead to view. Enough should be removed to fully expose the 
membrana tympani to inspection after the auricle is replaced and 
sutured in position. The proper prosecution of the after-treatment 
will largely depend upon the completeness with which this step of the 
operation is carried out. 

(d) The plastic meatal flaps should now be formed as in the radical 
operation. The operator's individual preference may be used, though it 

54 



850 



THE EAR 



is essential that the skin of the concha be included in the flaps, so as to 
enlarge the meatal opening and facilitate the application of the dress- 
ings to the mastoid wound. This procedure also aids in the inspection 
of the membrana tympani. The author has found the Ballance incision 
the most satisfactory for this purpose. The reader is referred to Figs. 
450 to 462 for the details of the various plastic meatal flaps, with the 
suggestion that in applying them to this operation, they should be so 
utilized as not to obstruct the opening made by the removal of the 
posterior bony wall of the auditory meatus. 



Fig. 466 




The removal of the posterior wall of the external auditory meatus down to the annulus tympanicus 
in the meatomastoid operation. Dotted lines indicate the amount to be removed. 



(e) Retract the meatal plastic skin flaps with the author's retractor 
to bring the membrana tympani into view, as shown in Fig. 472. This 
will greatly facilitate the next step in the operation, as it is necessary 
to see the membrana tympani during its performance. If the meatal 
retractor is not used the meatal flaps will constantly obstruct the view 
and hinder the operator in his work. 



CHRONIC MASTOIDITIS 



851 



(/) Insert a cannula, as recommended by Heath, into the aditus ad 
antrum via the antrum (Figs. 467 and 468), and with an attached rubber 
bulb, send blasts of air into the cavum tympani. The secretions and 
pedunculated granulations within the middle-ear cavity are blown out 
through the perforation in the membrana tympani into the auditory 
meatus. The middle ear may also be irrigated with the same apparatus. 

(g) If granulations or polypi are thus blown through the perforation, 
they should be grasped by small dressing forceps and removed. If they 
appear at the perforation, but do not protrude through it, they may be 
removed by gently pressing the forceps blades (one on either side of the 



Fig. 467 




Author's modified Heath operation (bony portion) complete. The curved cannula is inserted 
into the aditus ad antrum, preparatory to blowing blasts of air through the cavum tympani, to 
remove the secretions and debris. The author's meatus retractor makes the view of the mem- 
brana tympani possible during this procedure. 

perforation) against the margins of the perforation, thus bringing them 
within the grasp of the forceps. The blasts of air should be repeated 
until all the secretions, polypi, and debris are expelled from the tym- 
panic cavity. Tubes of various sizes should be at hand, so that one may 
be selected that fits the aditus ad antrum. It may be necessary to 
modify the shape of the antral aspect of the aditus with a small curette 
or hand burr, to adapt it to the cannula (Heath). If the tube is too 
small, it may pass so far into the aditus as to dislocate the incus and 
thus impair the hearing. 



852 



THE EAR 



(h) Having removed the secretions, polypi, and debris from the tym- 
panic cavity with the air blasts and forceps, place a small wet pad of 
cotton over" the perforation in the membrana tympani, and a small plug 
of the same material in the antral end of the aditus ad antrum to keep 
the blood and bone chips from entering the middle ear. 

(i) Anchor the plastic meatal flaps, as in the radical mastoid operation, 
with suitable stitches (Figs. 454 to 457). 



Fig. 468 




Schema of the ear, showing the method of cleansing the tympanic cavity after the Heath 
operation: a a, mastoid cells; b, antrum; c, aditus ad antrum; d, membrana tympani; e, per- 
foration in the membrana tympani; f, annulus tympanicus; h, external meatus, the posterior 
wall of which is removed; i, the auricle; j, silver cannula introduced through the opening in the 
posterior opening in the meatus, and thence forward into the aditus ad antrum; c, air pressure 
applied with a rubber bulb forces the secretions, granulations, etc., from the tympanic cavity 
through the perforation (e) in the membrana tympani into the meatus. 

(k) Introduce the tube dressing (Fig. 457) through the auditory 
meatus into the mastoid wound. Do not place it against the membrana 
tympani, but pass it backward through the opening in the posterior wall 
of the meatus into the mastoid cavity. If other forms of dressing are 
preferred, they should be introduced in the same manner. Whatever 
dressing is employed, it should be loosely placed, not packed, as its 
primary purpose is to facilitate drainage. Some operators recommend 
that gauze be firmly packed into the mastoid wound to "keep down" the 
granulations. If the operation is thoroughly done under aseptic con- 
ditions, exuberant granulations will not form; furthermore, good drainage 
lessens the tendency to their growth. Exuberant granulations are the 
product of infection, whereas healthy granulation tissue is formed in the 



CHRONIC MASTOIDITIS 853 

process of repair. Many cases pursue a prolonged process of repair 
because the dressings are packed in the mastoid wound. If the surgeon 
grasps the purpose of the wound dressing, namely, to promote drainage 
(and this alone), he will only insert enough gauze to carry away the 
secretions. The author uses a one-half to one inch strip of gauze in the 
rubber tube for this purpose and finds it adequate. If the foregoing 
technique is observed, exuberant granulations will not form nor will the 
healing process be prolonged. 

The ear should be covered with several large gauze pads, which should 
be removed in three days, the wound gently dried with a cotton-wound 
applicator introduced through the auditory meatus, and a new tube 
dressing applied. This should be changed daily. The sutures should be 
removed on the fifth day. 

The membrana tympani should be inspected daily, especially when the 
blasts of air are forced through the aditus ad antrum. After the mastoid 
wound is cleansed with the cotton-wound applicator the curved cannula 
should be introduced into the aditus via the meatus and the opening in 
the posterior wall of the meatus (Figs. 467 and 468) and blasts of air 
forced through the tympanic cavity to clear it of secretions and granu- 
lations. All granulations or polypi appearing at the perforation in the 
membrana tympani should be removed with forceps or with caustics. 
Heath insists upon the value of the blasts of air through the tympanic 
cavity until the aditus ad antrum becomes closed (eight to fourteen 
days). The author has followed his method and finds it to be of great 
value in the after-treatment. By it large quantities of mucus and pus 
are forced into the external meatus, from which they may be removed 
with a cotton-wound applicator. The secretions may also be removed 
by inflation through the Eustachian .tube, though this is not as efficacious 
as Heath's method. 

The secretions and granulations from the middle ear gradually subside 
as the perforation closes. The mastoid cavity becomes lined with 
epidermis and remains a dry cavity, and the Eustachian tube is no 
longer burdened with the secretions from this source. 

Of the forty-five cases thus operated by the author, in one, compli- 
cated by an epidural abscess over the tegmen tympani, it was necessary 
to convert into a radical operation. The membrana tympani re-formed 
in twenty-six cases, and the hearing returned to almost the normal in 
all but one. In this method of operation the mastoid wound is almost 
filled in the process of repair. 

Thiersch Grafts in the Mastoid Wound.— To Reinhard, Jansen, and 
Ballance belong the credit of applying the Thiersch grafts to the mastoid 
wound. Ballance has, perhaps, used it more constantly and frequently 
than anyone else, and his technique is generally followed. Personally 
the author has had but rare occasion to use it, as his cases usually became 
covered with epidermis in as short a time as is claimed by Ballance after 
the use of the Thiersch grafts. In only two cases has it been necessary 
to apply the grafts, and in these they were successfully applied after sec- 



854 



THE EAU 



ondary operations. By using the Ballance plastic meatal skin flaps, and 
fixing them as in Fig. 459, the author's cases have, with rare exceptions, 
healed with epidermis over the walls of the mastoid wound in from 
three to ten weeks, rarely longer. This good showing is due to several 
factors, chief among which are: (a) The Ballance plastic meatal flaps 
applied after the author's method, (b) The use of the spiral rubber 
tubing, with a small wick of gauze in its lumen as the sole drainage 
dressing. This dressing, as already explained, provides good drainage, 
which establishes conditions discouraging the formation of unhealthy 
granulations, (c) Another cause of the rapid epidermization of the mas- 
toid wound is the complete exposure and exenteration of the mastoid 




Hajek's hand burr. 

antrum and cells. The cells of Kirschner, between the antrum and mea- 
tus, and those in the posterior root of the zygoma and in the posterior 
wall of the pyramid of the petrous portion of the temporal bone are like- 
wise carefully sought for, and if present removed. 

If the surgeon finds that a considerable number of his cases pursue a 
prolonged course of healing, he should carefully scrutinize his technique, 
and, if found to be faulty at any point, improve it accordingly. If his 
cases still refuse to heal properly he may try the Thiersch grafts. 



Fig. 470 




Thiersch's graft razor. 

Technique. — (a) The grafts may be applied at the close of the primary 
operation, ten days after the primary operation, or after a secondary 
operation. Dench applies the grafts at the close of the primary opera- 
tion. Ballance ten days after the primary operation. The author 
only after a secondary operation; that is, only after it is conclusively 
shown that repair will not follow the primary operation. Since adopting 
the technique described in the radical mastoid operation, the author has 
not had more than 1 per cent, of cases requiring a secondary operation, 
whereas in his earlier practice it was about 10 per cent. 

(b) The patient's arm or thigh should be shaved and scrubbed twenty- 
four hours before grafting, a moist carbolized dressing applied, and held 
in position with a bandage. 



CHRONIC MASTOIDITIS 855 

(c) The patient should be anesthetized for the reason that (1) it 
prevents the "goose-flesh" contraction of the skin, which so materially 
interferes with cutting thin Thiersch grafts, and (2) it also prevents the 
pain incident to securing the grafts and opening the wound for their 
application. If the grafting is done at the time of the primary opera- 
tion, the patient is already anesthetized and the arm or thigh prepared 
when the mastoid region was shaved. 

(d) Rescrub the skin after the bandage and dressing are removed. 

(e) With the skin moistened ' with normal salt solution and drawn 
tight between the forefinger and thumb, remove the thin cortex by 
a rapid sawing motion with the broad Thiersch razor (Fig. 470). The 
razor is flat upon one side, while the other (the upper) is concave. Nor- 
mal salt solution should be dropped into the concave surface of the 
razor to float the graft. The size of the graft should be about 2x3 cm., 
or large enough to cover the entire bony wound. 

Fig. 471 




1 ; """■" --■ ,-niiriii- mii-wl-ra 



Thiersch's graft spatula. 

(J) Float the graft from the razor blade to the large spatula (Fig. 
471), using a teasing needle (Fig. 472) in transferring it. 

(g) The mastoid wound, having been previously opened and freed of 
all blood and oozing, is made the repository of the graft. With a teasing 
needle (Fig. 472) the edge of the graft is transfixed to the border of the 
mastoid wound and the spatula gradually withdrawn. The graft is 
thus deposited smoothly and evenly over the surface of the wound. If 
necessary, other grafts are applied. 

Fig. 472 



Teasing needle for Thiersch's grafting. 

(h) The grafts should be pressed against the walls of the wound with 
a small blunt instrument until they are closely adherent to the uneven 
surface (Fig. 474). A small glass pipette or medicine dropper may be 
used to withdraw bubbles of air from beneath the grafts. Some operators 
prefer to first fill the mastoid cavity with normal salt solution and float 
the graft upon its surface. The fluid is then gradually withdrawn with a 
pipette until the graft rests upon the surface of the bony wound. It is 
not necessary to engraft the entire surface of the wound, as the inter- 
spaces soon become covered by extension from the edges of the grafts. 

(i) Ballance formerly covered the grafts with very thin gold-foil to 
prevent the small cotton pads adhering to them and dislodging them 



856 



THE EAR 



when the dressing was removed. He now applies the cotton balls directly 
to the grafts, with good success. As a matter of fact, the grafts will 
remain in position, if properly adjusted (evenly and closely applied), 



Fig. 473 




The Thiersch graft being applied to the mastoid wound. 

without either gold-foil or the gauze pads. The postauricular wound 
should be reclosed with sutures after the grafts are applied and the 
subsequent dressings applied through the enlarged auditory meatus. 

Fig. 474 




The Thiersch graft in position. Other grafts 



itroduced until the entire bony surface is covered. 



(j) The small cotton balls are used to hold the grafts in apposition to 
the granulating bony wound, and they should be removed on the third 
day. Portions of the grafts will not "take" or grow, hence necrosis 



CHRONIC MASTOIDITIS 



857 



occurs, giving rise to a horrible stench. The engrafted area should be 
gently mopped dry with a cotton-wound applicator, the necrosed particles 



Fig. 475 




Mastoid incision made in infants: a, a, the proper location of the incision; the lower end of the 
incision should be about one-half inch posterior to its position in adults, in order to avoid injuring 
the facial nerve at its exit from the mastoid bone at b. 



Fig. 476 




Bezold's mastoiditis. The wound is closed with Michel's metal clamps, a, spiral tube draining the 
mastoid wound; b, spiral tube draining the abscess of the anterior triangle of the neck. An acces- 
sory incision is used to drain the abscess, as this will heal quickly after the tube is removed. If 
the tube makes its exit at the lower portion of the primary incision, healing will be slow and a 
scar left, as this is in the infected field. The portion of the incision below the mastoid also repre- 
sents the incision for the excision of the external jugular vein and for the removal of the glands 
of the neck. 



858 THE EAR 

removed, and a fresh dressing applied. The dressing should be renewed 
daily, as after the mastoid operation. 

Fig. 477 




Allport's mastoid retractor. 
Fig. 478 




Jansen's mastoid retractor. 



Fig. 479 




Allport's bone-crushing forceps. 
Fig. 480 



McKernon's rongeur forceps. 



It should be borne in mind, however, that Thiersch grafts will rarely 
be necessary if the cutaneous portion of the external auditory meatus is 



CHRONIC MASTOIDITIS 



859 



properly and intelligently utilized to line the mastoid wound, and if 
the cells are completely exenterated. 

The Mastoid Operation in Infants and Young Children. — As the mastoid 
tip and cells are but slightly developed before the age of puberty, the 
technique of the mastoid operation should be somewhat modified. The 
rudimentary tip of the mastoid process is located much higher and 
more posteriorly than in adults. 



Fig. 481 




Jansen's rongeur forceps. 
Fig. 482 




Reverdin's needle. 



Fig. 483 



Fig. 484 




Scheibel's suture forceps. 






Michel's metal clamp suture. 



Fig. 485 




Michel's suture clip forceps. 

The postauricular incision should, therefore, begin higher and more 
posteriorly, as shown in Fig. 475. Furthermore, the facial nerve makes 
its exit from the styloid foramen quite near the surface of the mastoid, 
and, if the incision is made as in adults, it may be injured and cause 
facial paralysis. The mastoid antrum is almost or fully developed at 
birth, and is often the only portion of the mastoid bone involved. 

The Surgical Treatment of Bezold's Mastoiditis. — The early surgical 
treatment is the only procedure that is applicable in this affection. 
The usual mastoid incision is made with an extension downward beyond 






860 THE EAR 

the tip of the mastoid, parallel with the anterior border of the sterno- 
mastoid muscle to the lowest portion of the brawny swelling of the 
neck. The aponeurosis of the sternomastoid muscle is divided and 
retracted. The mastoid is opened from below upward, toward the 
antrum. All the mastoid cells are thoroughly curetted until the perfora- 
tion in its inner plate is located. The perforation is followed into the 
loose tissues of the neck, and the granulations removed with a dull 
curette. The rough projections of bone are smoothed with a burr or 
curette and the ragged edges of the muscles are trimmed off with scissors. 
If the abscess has burrowed into the neck anteriorly or posteriorly, it is 
necessary to lay it wide open and thoroughly remove all diseased tissue 
with a curette. The mastoid portion of the incision should then be 
closed over a spiral tube with gauze in its lumen, the distal end of which 
is placed in the mastoid wound (Fig. 476). If the abscess extends into 
the neck, the incision should be closed over another spiral rubber tube, 
which is allowed to drain through a separate incision back of the lower 
end of the neck incision, as shown in Fig. 476. 

The dangers attending this operation are the wounding of the facial 
nerve at its exit from the bony canal in the mastoid process, and the 
spinal accessory nerve going to the trapezius muscle. If this nerve is 
wounded the shoulder will droop. The lateral sinus is also in close 
proximity to the perforation, hence great care should be taken in oper- 
ating in this region. 

If the disease is recognized early and prompt and thorough surgical 
measures are instituted the prognosis is fair, although the recovery 
may extend over several weeks, as the healing of the wound after such 
an extensive operation requires considerable time, and not infrequently 
a secondary abscess forms in the neck because of poor drainage. 



CHAPTER XLIX 

THE LABYRINTH: ITS PHYSIOLOGY, FUNCTIONAL 
TESTS AND DISEASE 

General Considerations. — Dr. Geo. E. Shambaugh has formulated 
some of the fundamental problems in reference to nystagmus as 
follows : 

(a) Normally the voluntary muscles of the eyes, body, and extremi- 
ties are under the influence of tonus impulses from the labyrinth. 

(6) The impulses from the two labyrinths are equal, though antago- 
nistic, and a state of equilibrium is maintained. 

(c) The sudden cessation of the tonus impulses from one labyrinth 
disturbs the equilibrium, and a spontaneous nystagmus, vertigo, 
nausea and vomiting, and ataxia result; that is, signs of destruction 
disharmony occur. In a slow destruction of one labyrinth extra- 
labyrinthine tonus develops as fast as the destruction of the labyrinth 
tonus occurs, hence the signs of destruction disharmony are absent. 

id) After the sudden destruction of one labyrinth, compensation 
takes place after a shorter or longer period of time. 

Physiology of the Semicircular Canals. — 1. The hair cells on one side 
of each crista are stimulated by an endolymph current in one direction, 
and the hair cells on the opposite side of the crista are stimulated by 
a current in the opposite direction (Plates XX and XXI). 

2. The hair cells on one side of a crista, when stimulated, produce 
nystagmus in the plane of its canal, and directed toward one side, 
while the stimulation of the hair cells on the opposite side of the same 
crista produce nystagmus in the same plane, but directed to the oppo- 
site side. The signs of stimulation disharmony occur in each instance. 

3. The reactions following the stimulation of the hair cells on the 
two sides of each crista are unequal and are in about the relation of 2 
to 1. This is well illustrated in Plate XXV in which the right labyrinth 
is totally destroyed. The patient is represented as being turned ten 
times to the right, with a resulting after-nystagmus of 12 seconds' dura- 
tion; after turning ten times to the left there is an after-nystagmus 
of six seconds' duration. This is due to the normal physiological 
difference in the potentiality of the two halves of the crista stimulated 
by the respective turnings. 

4. In each canal the greater reaction follows the stimulation of 
these hair cells, impulses from, which direct the nystagmus toward 
the same side (canal half in horizontal and utricular half in superior 
and posterior canals, Plates XX and XXI). 

5. Tonus impulses from the labyrinth have their origin in the hair 
cells of the crista?. From each labyrinth, therefore, arise tonus impulses 

(SGI) 



862 THE EAR 

for the muscles which direct nystagmus to the same side, as well as 
nystagmus to the opposite side. The stronger tonus impulses from the 
labyrinth are those which go to the muscles directing the nystagmus 
to the same side. When the tonus impulses from one labyrinth are 
suddenly suppressed, as in diffuse manifest suppurative labyrinthitis, 
the equilibrium between the two labyrinths is disturbed, and the 
tonus from the normal labyrinth, acting without the restraint of the 
impulses from the opposite side, produce nystagmus directed toward 
the normal or opposite side (Plate XXV). (Signs of destruction dis- 
harmony.) 

Compensation in sudden destruction of the labyrinth occurs (1) by 
extralabyrinthine compensatory increase in tonus, and (2) by com- 
pensatory increase in tonus of the opposite or normal labyrinth. 

In some cases compensation may take place entirely independent 
of the healthy labyrinth, that is, it may be entirely extralabyrinthine. 

In very old cases of unilateral destruction it is possible that the two 
halves of each crista of the remaining healthy labyrinth become equal 
in tonus impulses, as is suggested by the fact that the rotation in 
either direction produces nystagmus of equal intensity and duration 
(Plate XXVIII). 

In sudden destruction of one labyrinth there is not only the loss of 
labyrinthine tonus from this side, but there is a suppression of extra- 
labyrinthine tonus. Monakow calls this diaschisis. The rapid recov- 
ery from the disturbed equilibrium (nystagmus, nausea, vomiting, 
dizziness, ataxic gait, etc.) is due to the restoration of the extralaby- 
rinthine tonus, i. e., the diaschisis rapidly subsides. The establish- 
ment of compensatory tonus in the remaining labyrinth is established 
much more slowly, often requiring years. Indeed, much of the com- 
pensatory tonus, other than that which occurs soon after the destruc- 
tion, is extralabyrinthine in origin, as is shown by the fact that for a 
long time after compensation under ordinary conditions seems perfect, 
turning in one direction will produce a longer and more severe nystag- 
mus than turning in the opposite direction. This shows that laby- 
rinthine compensation is not complete (Plate XXV). Those cases of 
very long standing, as shown by Ruttin, had nystagmus of equal 
duration and intensity by turning in either direction, though of shorter 
duration than normal (Plate XXVIII). 

After rapid total destruction of one labyrinth the process of recovery 
of static function is about as follows: 

(a) The diaschisis or suppression of extralabyrinthine tonus quickly 
disappears, and the symptoms or signs of destruction disharmony are 
correspondingly relieved. 

(b) Compensatory extralabyrinthine tonus gradually develops, though 
perhaps more rapidly than the compensatory labyrinthine tonus in the 
healthy labyrinth. 

(c) Compensatory labyrinthine tonus also develops, until after several 
years the impulses from two sides of the crista of the healthy labyrinth 
become equal (but of shorter duration than normal), a fact which 



THE LABYRINTH 863 

makes it appear probable that the extralabyrinthine compensatory 
tonus has subsided to its normal plane again. 

All afferent impulses affect the static centres of the cerebellum, 
though those from the labyrinth are probably more defined and effec- 
tive, as this is a highly specialized organ of special sense. 

A sharp distinction should be drawn between induced nystagmus 
and spontaneous nystagmus. Induced nystagmus is due to an exces- 
sive artificial stimulation of a crista ampullaris, and is attended by 
induced "signs of stimulation disharmony," as a preponderance of 
nervous impulses emanates from the stimulated labyrinth (Plates XIX 
and XX). In circumscribed labyrinthitis the nystagmus is spontaneous 
and may be directed to either side. In diffuse suppurative manifest 
and in diffuse suppurative latent labyrinthitis and in diffuse serous 
labyrinthitis, the spontaneous nystagmus is due to the sudden, and 
total or partial, suppression of nervous impulses from the diseased 
labyrinth. We should expect, therefore, in diffuse labyrinth disease, 
to find the "signs of destruction disharmony," while in circumscribed 
labyrinthitis we may find either the signs of stimulation or of destruc- 
tion disharmony, or both (Plates XXI, XXII, and XXVIII). When 
both ears are normal spontaneous nystagmus is absent, but it may be 
induced. 

By reference to Plate XIX we are enabled to explain the various 
nystagmic phenomena which occur upon artificial stimulation of the 
crista of the superior canal. That is, this plate illustrates the mechan- 
ism of the induced nystagmus (signs of "stimulation disharmony"), 
by the various physiological tests. 

Anatomical Data. — Certain anatomical facts to be taken into con- 
sideration in arriving at correct physiological and clinical conclusions 
are illustrated in Plate XIX as follows: 

1. The utricular half of each crista ampullaris of the superior canal 
emits stronger tonus impulses to Deiters' nucleus than the canal half, 
and as a consequence the utricular half of the crista exerts more pull or 
potentiality than the canal half. The ratio is about 2 to 1 (Plate XXV). 

2. The right Deiters' nucleus (D.N.) sends fibers to the abductors 
and the adductors of both eyes, but it sends stronger impulses to the 
abductor of the left eye, and to the adductor of the right eye than it does 
to the opposing muscles, i. e., the abductor of the right and the adduc- 
tor of the left; hence, when the right crista ampullaris is stimulated 
there is a preponderence of pull or potentiality exerted upon the abduc- 
tor of the left eye, and the adductor of the right eye, with a resultant 
conjugate movement of both eyes to the left, the slow component of the 
nystagmus. This movement of the eyes stimulates a nervous impulse in 
the left cortical centre (L.C.C.) which is transmitted to the nuclei, III 
and VI of the right side, and from thence to the abductor muscles of 
the right eye, and the adductor muscle of the left eye (Plate X1XV 
This results in a conjugate movement of both eyes to the right. This 
movement is more rapid, though of the same amplitude, than the 
primary slow movement, and is known as the quick component of the 



864 THE EAR 

nystagmus. In other words, when there is an excessive stimulus or 
excess of tonus in the right crista ampullaris, a slow conjugate move- 
ment of the eyes to the left occurs, which excites a reflex impulse in 
the cortical centre (R.C.C.) which immediately produces a quick 
conjugate movement of the eyes in the opposite direction. These 
two movements constitute nystagmus of vestibular and cerebellar 
origin. The nystagmus takes its name from the direction of the quick 
component, hence, when the quick component is to the right the 
nystagmus is said to be to the right, said vice versa. When there is a 
destruction or inhibition of one labyrinth, from disease, the nervous 
impulses emanating from the sound labyrinth preponderate over those 
from the destroyed or inhibited labyrinth and produce spontaneous 
nystagmus in the opposite direction to that which would be induced 
by stimulation, provided the destroyed labyrinth could be stimulated. 
When testing the vestibular apparatus the "signs of stimulation dis- 
harmony" are induced, whereas, in acute disease of the labyrinth 
the "signs of destruction disharmony" are spontaneously manifested. 
When the acute disease becomes latent (without the signs of destruc- 
tion disharmony) there are no symptoms referable to the vestibular 
labyrinth, except upon experimental tests of the labyrinth. 

3. The crista ampullaris of each semicircular canal is an end-organ 
of the vestibular nerve, and plays an important part in maintaining 
the equilibrium of the body under normal conditions. In labyrinth 
disease, and under excessive induced stimulations, a disturbed state 
of equilibrium, and nystagmic movements of the eyes, known as the 
"signs of destruction disharmony," and the "signs of stimulation 
disharmony," respectively, are present. 

4. The canal side, and the utricular side of the crista are not endowed 
with the same degree of pull or potentiality, and each acts upon oppos- 
ing sets of voluntary eye muscles (as well as those of the body). That 
is, when the utricular side of the crista ampullaris ( + ) of a superior 
canal is stimulated (Plate XIX) a nystagmus of a greater degree is 
produced than when the canal side ( — ) is stimulated, and produces a 



PLATE XIX 

Diagrammatic Illustration of the Turning, Caloric, and Galvanic (Induced) 
Nystagmus. 

1. The green arrows indicate the flow of endolymph after turnings to the right 
have ceased. The head is inclined 90 degrees forward during the turnings. In the 
right superior canal the impact of the endolymph is against the canal half of the 
crista ampullaris ( — ), which gives off a nervous impulse about one-half as strong 
as is given from the utricular half. In the left superior canal the impact of the 
endolymph is against the utricular half of the crista, which. in consequence, gives 
off a nervous impulse about twice as strong as is given off from the canal half of 
the crista. Both impulses are transmitted via the red lines (b and /) to Deiters' 
nuclei (D.N. and D.N.) and from thence to the third and sixth nuclei of the right 
side (/// and 77) to the abductor muscles of the right eye (R), and to the adductor 
muscles of the left eye (L). The strength of the impulse arising in the canal half 
of the right crista and in the utricular half of the left crista is in the ratio of 1 to 2, 
and they conjointly cause the eyes to turn slowly to the right (slow component of 
the nystagmus). A corrective impulse is immediately excited in the cortical centre 



PLATE XIX 




^>£ 



Turning, Calorie, and Galvanic Induced Physiological Nystagmus 



THE LABYRINTH 865 

of the left hemisphere of the brain (L.C.C.) which is transmitted to the third and 
sixth nuclei of the left side (III and VI), and from thence to the abductor muscles 
of the left eye (L), and to the adductor muscles of the right eye (R). As a result of 
this corrective impulse the eyes are quickly turned to the left (quick component of 
the nystagmus). This reaction is known as induced rotatory after-nystagmus to 
the left, and is symbolized thus ^~* 1. It is referred to as induced because 
it is artificially produced by unaccustomed turnings, and it is rotatory because it 
emanates from the superior canals. The plane of the nystagmus is, according to 
Fleurens' law, always in the plane of the canals stimulated. The plane of the superior 
canals is frontal, hence the eyes rotate upon their pupillary axes. 

2. The black arrows indicate the direction of the downward flow of endolymph 
in the right superior canal after irrigation of the right ear with cold water (78°) 
with the head erect. The impact of the endolymph is against the canal half of 
the crista. This gives rise to a nervous impulse which is transmitted through the 
path shown as a red line (b) to Deiters' nucleus (D.N .), and from thence to the third 
and sixth oculomotor nuclei of the right side (III and VI), whence it is conveyed 
to the abductor muscles of the right eye (R) and to the adductor muscles of the 
left eye, thus inducing a slow conjugate movement of both eyes to the right (slow 
component of nystagmus). A corrective impulse is thereby stimulated in the left 
cortical centre (L.C.C.) which is transmitted to the third and sixth oculomotor nuclei 
of the left side, from whence it is conveyed to the adductor muscles of the right 
eye (R) and to the abductor muscles of the left eye, thereby causing a quick rotatory 
movement of both eyes to the left (quick component of the nystagmus), which is 
symbolized thus, ^-* 1. Cold irrigation (78°) therefore induces rotatory nystagmus 
to the opposite side. 

3. When warm irrigation (120°) is used the flow of endolymph is upward (the 
reverse of what it was with cold irrigation 78°), hence the impact of the endolymph, 
as indicated by the red arrows, is against the utricular half of the crista (+), which 
sends a nervous impulse through the paths indicated by the blue lines (a, a) to 
Deiters' nucleus (D.N.). From thence it is transmitted to the third and sixth (III, 
VI) oculomotor nuclei of the opposite (left) side, and thence to the adductor muscles 
of the right eye (R) and to the abductor muscles of the left eye, thereby causing a 
conjugate slow movement of both eyas to the left (slow component). A cortical 
correction impulse immediately arises in the right cortical centre (R.C.C.), and 
acting through the third and sixth oculomotor nuclei of the right side, produces 
a quick conjugate movement of both eyes to the right (quick component of the 
nystagmus). The nystagmus is induced, rotatory and to the right, and is symbo- 
lized thus: ^-a r. Warm irrigation (120°) induces rotatory nystagmus to the same 
side. 

4. When the kathode or negative pole of a galvanic battery is applied to the 
right ear a nervous impulse is transmitted through the paths indicated by the 
blue fines (a, a) to Deiters' nucleus (D.N.), and thence to the third and sixth oculo- 
motor nuclei (III, VI) of the left side, and thence to the adductor muscles of the 
right eye (R) and the abductor muscles of the left eye (L), thereby inducing a 
slow conjugate movement of both eyes to the left (slow component). The cortical 
corrective impulse is immediately sent out from the right cortical centre (R.C.C.) 
to the third and sixth oculomotor centres of the right side (III, VI), and from thence 
to the abductor muscles of the right eye (R) and the adductor muscles of the left 
eye (L), thereby inducing a quick conjugate rotatory movement of both eyes to 
the right (quick component). The kathodal (negative) galvanic current therefore 
induces rotatory nystagmus to the same (right) side, and is symbolized thus:/-^ r. 

5. When the anode or positive pole of the galvanic battery is applied to the 
right ear, nystagmus to the opposite side is induced. The anode appears to 
inhibit or suppress the nervous impulses in the vestibular apparatus over which 
it is applied, thus leaving a preponderance of tonus in the opposite labyrinth. The 
greater impulse or tonus is therefore transmitted through the paths indicated by 
the red lines (/) of the left side, which pass through the left Deiters' nucleus to the 
right oculomotor nuclei (III, VI) to the abductor muscles of the right eye and* the 
adductor muscles of the left eye, thereby producing a slow conjugate movement of 
both eyes to the right (slow component). The cortical correction impulse imme- 
diately arises in the left cortical centre (L.C.C.) and is transmitted through the 
left oculomotor centres (///, VI) to the adductor muscles of the right eye. and 
abductor muscles of the left eye, thereby producing a quick conjugate movement 
of both eyes to the left (quick component of the nystagmus). The anode applied to 
the right ear (the kathode in the hand) induces rotatory nystagmus to the opposite 
(left) side, and is symbolized thus: s~^ 1, 

55 



866 THE EAR 

movement of the eyes in an opposite direction to that produced by 
stimulation of the other half of the crista. In the horizontal canal the 
stronger nystagmus is produced by stimulation of the canal side of 
the crista, and here again, the stimulation of each half of the crista pro- 
duces movements of the eyes in a direction opposite to that produced 
by the other half of the same crista. 

5. Each crista ampullaris forms a ridge across its respective ampulla, 
and is surmounted by hair cells, the hairs of which project into the 
under surface of the gelatinous cupola. The cupola with its hair cells 
is a special end-organ of the vestibular nerve, and receives the impact 
of the endolymph current. Dr. Shambaugh claims that if the cupola 
were actually bent in either direction by the endolymph current, it 
would be torn from its attachment. The impact or impulse of the 
endolymph current is "sensed," but the cupola is not bent or inclined 
in either direction by the current. Whether they are actually bent 
by an endolymph current, or that they only "sense" the impact of 
the endolymph, is not actually proved. 

The Static Labyrinth. — The term static labyrinth refers only to 
the semicircular canals and the crista? ampullares, the end-organs 
of the vestibular nerve. The function of the end-organs of the utricle 
and saccule has not been clearly defined. It has been supposed that 
one has something to do with the orientation of vertical movements, 
and the other with horizontal movements of the body, but this has 
not been proved. The function of the crista? located in the ampullae, 
have, however, been quite clearly determined, and it is to these end- 
organs of the vestibular nerve that we will confine our consideration. 

In the ampulla of each semicircular canal is located a crista, which, 
upon stimulation, gives off nervous impulses that are transmitted 
through the vestibular nerve to Bechterew's, Deiters', and the angular 
nuclei in the cerebellum, and from these centres the impulses are 
distributed to the nuclei of the third and sixth cranial nerves, which 
supply the extra-ocular muscles of the eyes, and to the muscles of the 
body and extremities. These impulses, when thus distributed, cause 
certain "reaction movements" of the eyes, body, and extremities. 
Under normal conditions these "reaction movements" maintain the 
equilibrium of the body and eyes; hence, the portion of the labyrinth 
giving off these nervous impulses is known as the static labyrinth. 
When, however, the potentiality of these impulses is either lost or 
exaggerated by disease, or physiological stimulation, the eyes are 
affected by nystagmus; ataxia, nausea, and vomiting may also occur. 
In disease of the labyrinth the nervous impulses given off by the diseased 
labyrinth are always, or nearly always, either diminished or altogether 
abolished, except in circumscribed labyrinthitis. The cochlea which 
presides over the function of hearing may be spoken of as the auditory 
labyrinth; the utriculus saccule and semicircular canals, as the static 
labyrinth; and the whole, as the static-auditory labyrinth. 1 

1 It is now thought by some investigators that the cristas have direct connection with the third 
and sixth oculomotor centres, 



THE LABYRINTH 867 

Static Impulses. — The impulses emanating from the cristas ampul- 
lares may be of three types, namely (a) normal, (b) increased, and 
(c) decreased or abolished. 

(a) The normal static impulses are those excited in normal individuals 
by the ordinary movements and positions of the head. There is no 
consciousness of orientation, as they are normal under ordinary con- 
ditions of life. 

(b) Increased static impulses are those which occur spontaneously 
without extra otitic stimulation, or which occur in response to slighter 
stimulations than those required to produce them in normal individuals; 
or the increased impulses may be due to extraordinary stimulation, 
as in the turning and caloric tests. Individuals having these increased 
static impulses are hypersensitive to vestibular stimulations. 

(c) The decreased static impulses are those which can only be 
excited by extraordinary movements of the head, or other violent 
stimulation, as heat, cold, galvanism, and by compression or aspiration 
of the air in the meatus. Decreased static impulses are found only in 
individuals with a partially destroyed static labyrinth. (Partial loss 
of static impulses is sometimes present in circumscribed and in mild 
forms of serous labyrinthitis.) Static impulses are altogether abolished 
in diffuse manifest and diffuse latent suppurative labyrinthitis, and 
the fifth degree of serous labyrinthitis, in hemorrhage of the labyrinth, 
as in Meniere's disease, and fractures through the petrous portion of 
the temporal bone. 

Spontaneous Nystagmus. — Spontaneous nystagmus of static laby- 
rinth origin is characterized by rhythmical movements of the eyes, the 
movement in one direction having more speed than the movement in 
the opposite direction. The slow component is caused by the nervous 
impulse emanating from the crista or cristas of the static labyrinth. 
The quick component is caused by a reflex impulse from a cortical 
centre. If the function of the cristas is suddenly inhibited or destroyed 
by disease, the impulses emanating therefrom are diminished or alto- 
gether lost, whereas, if the diseased labyrinth is not destroyed or 
suppressed, but is stimulated, has an exaggerated tonus, the impulses 
causing the slow component of the spontaneous nystagmus emanate 
from the diseased static labyrinth, i. e., a preponderance of impulse 
tonus or potentiality emanates from the diseased labyrinth, and this 
sudden change in the balance of tonus causes the nystagmus. As com- 
pensation occurs the nystagmus subsides. In one instance "the signs 
of destruction disharmony" and in the other the "signs of stimulation 
disharmony" are present. As a matter of fact, we do not find stimula- 
tion disharmony present in disease of the labyrinth except in some 
cases of circumscribed labyrinthitis, and in congestive disturbances 
of the labyrinth in the course of acute otitis media. When stimulation 
disharmony is present in acute otitis media it should not be regarded 
as a sign of labyrinth disease, but as a circulatory disturbance in the 
labyrinth. Spontaneous nystagmus is usually a combined horizontal 
and rotatory movement of the eyes. From a purely theoretical view 
the two labyrinths participate in the induced nystagmus. 



868 THE EAR 

Reaction Movements. — While nystagmus is in reality a reaction 
movement of static labyrinth origin, it is not generally referred to as 
such. The term "reaction movement" will, therefore, only be used 
to designate those movements of the body and extremities which are 
caused by nervous impulses emanating from the static labyrinth in 
ear disease, and certain centres in the brain, as in cerebellar disease. 

Reaction movements of the body and extremities are also induced 
by the physiological tests, as the turning, caloric, galvanic, and fistula 
experiments. We may therefore deduce the law that physiological 
stimulation of one static labyrinth, or fulminating or progressive disease 
of one static labyrinth, is always accompanied by nystagmus, and the 
"reaction movements" of the body and extremities, as ataxia, nausea, 
and vomiting, until compensation occurs. Compensation occurs after the 
vestibular tests in from ten to forty-five seconds; in disease from a few 
minutes or hours to a few weeks. 

It has also been shown by experiments upon animals, that when 
both labyrinths are simultaneously destroyed neither nystagmus nor 
reaction movements occur. It has been shown that after the surgical 
destruction of a labyrinth, compensation occurs much more rapidly 
than after destruction by some pathological process. 

The reaction movements may be of the spontaneous or of the. induced 
type. Spontaneous reaction movements are present in certain types 
and stages of labyrinth disease, and in cerebellar disease. They are 
only present a few minutes, hours, days, or weeks, in labyrinth disease, 
but may be present indefinitely in cerebellar disease. A stronger 
stimulation is necessary to induce reaction movements than to induce 
nystagmus. This is true of either the spontaneous or induced reaction 
movements. 

The reaction movements of static labyrinth origin consist of a sense 
of surrounding objects rotating around the body or of the rotation of 
the body, and of nausea, vomiting (sometimes), and ataxia, with a 
tendency to fall toward the slow component of the nystagmus. In 
cerebellar disease the direction of the slow component exerts no 
influence on the direction of falling. 

Pointing toward the slow component of the spontaneous nystagmus 
of static origin is the normal reaction in Barany's pointing test. WTien, 
therefore, a patient affected by spontaneous nystagmus points to the 
quick component, or points directly to the finger of the observer, 
the result is said to be abnormal or suggesting cerebellar disease (see 
Pointing Test). 

The reaction mc^°ments are not of as much clinical importance 
as nystagmus, though they afford valuable information concerning 
disease of the static labyrinth, and more especially concerning cere- 
bellar disease. According to Barany the reaction movements consist 
of voluntary movements, the impulses of which are modified in their 
transmission through the cerebellar cortex by normal impulses from 
the crista? ampullares of the semicircular canals. That is, in the cere- 
bellar cortex, motor impulses from the cerebrum are met by centripetal 



THE LABYRINTH 869 

impulses from the semicircular canals. If these centripetal impulses 
are abolished on one side by disease, or by abnormal stimulation of the 
semicircular canals in physiological experiments, the normal volun- 
tary movements are changed in such a way as to result in reaction 
movements (Braun and Freisner). Inasmuch as the will-power and 
voluntary movements are factors in the reaction movements, they 
are not as reliable data upon which to estimate pathological processes 
as the nystagmus, in which the will-power and voluntary movements 
are not important factors. In children the will-power and muscle 
sense are not as highly developed as they are in adults, hence the 
reaction movements are better developed in children than in adults. 
Notwithstanding this, the reaction movements are of great value in 
determining the condition of the static labyrinth and cerebellum, as 
follows : 

(a) The failure to induce nystagmus and reaction movements by 
the caloric and fistula tests, signifies destruction of the static labyrinth. 
In such a condition infection within the labyrinth might, without 
symptoms, extend to the meninges and brain until actual meningitis 
or cerebellar abscess was developed, hence there is an element of danger 
waiting for developments in such a case. 

(b) When nystagmus and reaction movements are induced by 
slighter stimulation than is required in normal individuals (except 
in neurasthenics) it signifies an increased irritability of the static 
labyrinth, due to congestion of the labyrinth, as is occasionally found 
in acute otitis media. This should not be regarded as disease of the 
labyrinth. 

(c) When nystagmus and the reaction movements require excessive 
stimulation, as by the caloric test, to induce them, it signifies dimin- 
ished irritability of the static labyrinth, as in certain types of circum- 
scribed and serous labyrinthitis. 

An increased intensity of reaction signifies a congestion or mild 
inflammation of the labyrinth and a diminished intensity of reaction 
means active disease of the static labyrinth with partial suppression 
or destruction of function. Total abolition of the reaction means the 
destruction of the labyrinth in diffuse suppurative labyrinthitis. 

The quantitative estimation of the irritability of the labyrinth has 
reference to either the presence or absence of nystagmus and ataxic 
symptoms; that is, the tests are made to determine whether or not 
nystagmus and ataxia can be induced. If one labyrinth is totally 
destroyed, the caloric test applied to the affected ear will not induce 
nystagmus and ataxia, i. e., the static irritability is negative in quantity. 
The caloric test applied to a normal ear will induce nystagmus and 
ataxia, i. e., the static irritability is positive in quantity. 

The qualitative estimation of the irritability of the static labyrinth 
has reference to the degree of stimulation required to induce nystagmus, 
its duration and intensity, and is made in three ways, as follows: 

(a) By the " Reizxchwelle" or strength of irritation, necessary to 
induce nystagmus. If the turning test is used, the number of rotations 



870 THE EAR 

required to induce nystagmus is noted. If the caloric test is used the 
temperature and amount of water required and the number of minutes 
necessary to produce nystagmus are noted. 

(6) The qualitative estimation of labyrinth irritability is also made 
by determining the duration of the nystagmus with a constant strength 
and duration of the stimulation with Ruttin's double irrigator. 

(c) By galvanism with a double electrode (from one pole of the 
battery) applied to both ears simultaneously, the other pole being 
held in the hand. 

The turning test is also used for the quantitative test. 

The Cristae AmpuHares. — The cristas ampullares are the special 
end-organs of the vestibular nerve and are situated in the ampullae 
of the semicircular canals. Each crista functionates on the plane of 
its associated canal. That is, stimulation of the crista of the horizontal 
canal produces nystagmus in the horizontal plane. Stimulation of the 
crista of the superior canal produces rotatory nystagmus on the frontal 
plane, etc. If the cristas of the horizontal and superior canals are simul- 
taneously stimulated, as in the warm caloric test, a combined horizontal 
(weak) and rotatory (strong) nystagmus follows. As has been previ- 
ously stated, each crista is a double end-organ, one-half producing 
nystagmus to one side, and the other half to the opposite side, but 
in each instance in the same plane of the canal or canals stimulated. 

The Cristae of the Utricle and Saccule. — In the utricle and saccule 
are end-organs somewhat similar to the cristae ampullares, the function 
of which has not been definitely determined, though it is supposed to 
influence the orientation of movements in the vertical and horizontal 
planes. 

Spontaneous and Induced Nystagmus in Relation to Vestibular 
and Cerebellar Disease. — Before discussing nystagmus in relation to 
disease of the cerebellum and vestibular apparatus, a clear distinction 
between spontaneous and induced nystagmus should be made. 

Spontaneous Vestibular Nystagmus. — This form of nystagmus occurs 
in acute diffuse suppurative manifest labyrinthitis, acute serous laby- 
rinthitis, and at intervals in circumscribed labyrinthitis, and is gener- 
ally due to either inhibition or destruction of the vestibular apparatus 
of the affected side, except in circumscribed labyrinthitis, and acute 
congestion of the labyrinth accompanying acute otitis media. In the 
latter disease the nystagmus is due to congestion of the labyrinth. 
Induced nystagmus may be elicited for diagnostic purposes in normal 
cases, and in the course of labyrinth disease after the spontaneous 
nystagmus has ceased, and when spontaneous nystagmus is present 
it may be made either more or less manifest by the usual procedures for 
inducing nystagmus. When one labyrinth is destroyed, as in diffuse 
latent suppurative labyrinthitis, or fracture through the base of the 
skull, and extralabyrinthine compensation has occurred, induced nys- 
tagmus may be elicited by stimulating the healthy labyrinth, thereby 
increasing the potentiality or tonus of its impulses. If one labyrinth is 
only partially disabled, as in the milder forms of serous labyrinthitis, 



THE LABYRINTH 871 

the other labyrinth being normal, or when both are normal, induced 
nystagmus may be caused by a stimulation of the crista?, thereby 
establishing a discrepancy between the potentiality, pull, or tonus 
impulses emanating from the two vestibular apparatuses. The sudden 
disturbance of the existing balance of tonus causes the nystagmus. 

Spontaneous vestibular nystagmus lasts for only a few minutes, hours, 
days, or weeks after the crista? are inhibited by compression in diffuse 
serous labyrinthitis, or by destruction in diffuse suppurative manifest 
labyrinthitis. In circumscribed labyrinthitis it occurs in periodic 
attacks, brought on by jarring movements, and independently of 
jarring movement of the head. The periodic attacks of spontaneous 
nystagmus, occurring independently of jarring movements, are espe- 
cially characteristic of circumscribed labyrinthitis. 

In spontaneous vestibular nystagmus the discrepancy of poten- 
tiality, pull, or tonus impulses, is generally due to a sudden decrease, 
or total loss of irritability of the crista from disease, thus decreasing 
or abolishing its potentiality; the crista? of the healthy labyrinth retain- 
ing their normal potentiality or tonus. When spontaneous nystagmus 
is to the healthy side, the affected vestibular apparatus may generally 
be assumed to be suppressed, as in serous labyrinthitis, or wholly 
destroyed, as in diffuse suppurative manifest labyrinthitis, the healthy 
side remaining normal in tonus, and producing the slow component 
of the nystagmus. With such an imbalance existing between the two 
labyrinths it would at first appear that spontaneous nystagmus should 
continue indefinitely. Its disappearance is due, however, to accommo- 
dation, readjustment of function, or compensation extraneous to the 
labyrinths, rather than between the two labyrinths. The compensa- 
tion takes place chiefly outside of the labyrinths, though it may take 
place in the healthy labyrinth. To induce nystagmus it is now neces- 
sary to artificially disturb the existing "compensating extralabyrin- 
thine tonus," by either the turning, caloric, or fistula test. According 
to Neumann it is possible that spontaneous nystagmus may altogether 
be absent when there is a very exaggerated tonus in the two centrums, 
because of their close approximation. 

Characteristics of Spontaneous Vestibular Nystagmus. — Spontaneous 
nystagmus may be said to occur in three degrees, namely : 

(a) The first degree. 

(b) The second degree. 

(c) The third degree. 

The first or weakest degree only occurs when looking toward the 
quick component, and ceases when looking straight ahead, or to the 
slow component. G. W. MacKenzie has shown that many persons 
with normal ears have nystagmus when looking to the extreme right 
or left, hence, if there was no history of spontaneous nystagmus 
previously the first degree nystagmus should be regarded as physio- 
logical nystagmus. When first degree nystagmus is present in disease 
of the labyrinth it is usually stronger when looking to the diseased side, 
a point which may differentiate it from physiological nystagmus. 



872 THE EAR 

The second or medium degree of nystagmus occurs when the patient 
looks toward the quick component, and when looking straight ahead, 
and it ceases when looking toward the slow component. 

The third or strongest degree of nystagmus occurs when looking in 
any direction. That is, it cannot be stopped by looking in any direc- 
tion, even to the slow component, and more often occurs at the begin- 
ning of acute diffuse suppurative and serous labyrinthitis, and gradually 
becomes weaker and weaker, more easily stopped, as it fades into the 
second and first degrees. 

Cerebellar Nystagmus. — Cerebellar nystagmus may be either spon- 
taneous or induced, and is usually to the affected side, whereas in 
destructive disease of the labyrinth it is to the opposite or healthy 
side. It is spontaneous when there is disease or irritation in that 
portion of the cerebellum in which the vestibular centrums (Deiters' 
and Bechterew's and the angular nuclei) and the vestibulocerebellar 
tracts are located, and is a sign of stimulation disharmony. Cerebellar 
nystagmus may be induced by the galvanic test when the labyrinth 
is destroyed and the vestibulocerebellar tract and the nuclei are still 
intact. After the destruction of the labyrinth, the vestibulocerebellar 
tract is gradually destroyed by ascending degeneration, until, finally, 
the central nuclei on the same side are invaded by the degenerative 
process, and the destruction is complete. G. W. MacKenzie has 
shown that rhythmic nystagmus may be induced without vertigo by 
mild galvanic stimulation. It has been known, however, that nystag- 
mus is more easily invoked than the reaction movements. A stronger 
stimulation would have induced the vertigo and disturbance of equi- 
librium. 

If the galvanic test is applied, from time to time, the progress of 
degenerative process may be noted and estimated. Soon after the 
destruction of the labyrinth, the induced cerebellar nystagmus, by 
galvanization (see Galvanic Test) is pronounced. As tests are made 
from time to time, the reaction gradually becomes weaker and weaker, 
until finally, after many months or years, it ceases altogether, as the 
vestibulocerebellar tract and centrums are completely destroyed by 
the degenerative process. (See Plates XIX, XXIII, and XXV.) 

The character of cerebellar nystagmus is somewhat similar to vestibu- 
lar nystagmus, though it differs in a few particulars. It has a slow and 
quick component, but is more irregular in its oscillations, and appears 
at intervals. Its direction is usually to the affected side, though it 
may be to the healthy side (Plate XVII). If the cerebellar nystagmus 
is produced by the irritation of the centrum from toxic material or 
congestion, the nystagmus will be to the same side as the disease. If 
however, the cerebellar disease compresses or paralyzes the centrum, 
the nystagmus will be to the healthy side. As both centrums are 
situated near the median line it is quite possible that the cerebellar 
disease may affect the centrum on the opposite side, rather than the 
one on the same side. The spontaneous nystagmus may not be mani- 
fest until opaque spectacles are applied to the eyes. The foregoing 



THE LABYRINTH 873 

facts explain the variableness in the direction of nystagmus in cere- 
bellar disease, as basal meningitis, abscess, and tumors. Cerebellar 
nystagmus tends to continue indefinitely, and to increase in intensity, 
as the disease causing it continues and progresses indefinitely; whereas 
spontaneous vestibular nystagmus rapidly decreases in intensity, and 
after a few minutes, hours, days, or weeks, ceases altogether, especially 
after destruction of the labyrinth by diffuse manifest suppurative 
labyrinthitis, and after inhibition by diffuse serous labyrinthitis (Plates 
XVII and XXV). There is, however, great variableness in the expres- 
sion of cerebellar nystagmus. The disappearance of the spontaneous 
nystagmus is not due to the disappearance of the disease, but chiefly to 
extralabyrinthine compensation. The persistence of nystagmus over 
many days, weeks, or months, is therefore strongly indicative of cere- 
bellar disease, as abscess, tumor, or tubercle, in the cerebellopontine 
angle. Cerebellar nystagmus due to the toxemia of erysipelas ceases 
with the disappearance of the erysipelas, and does not tend to be 
indefinitely prolonged, as in tumors and abscess of the cerebellum. 

Cerebellar Nystagmus due to Erysipelas of the Scalp and Face. — 
Erysipelas of the face or scalp may be attended by severe headache, 
congestion, and toxemia of the cerebellum; hence spontaneous nystag- 
mus to the same side mav be present in this disease, and is due to 
congestion, or to the stimulus of the toxic products. The centrums 
are stimulated as in cerebellar disease. According to Ruttin, who 
first made these observations upon erysipelas in the mastoid region, 
spontaneous nystagmus may be the earliest sign of erysipelas, as it 
sometimes occurs before redness of the skin. In six cases of erysipelas 
shown me by him, in April, 1911, the nystagmus was to the diseased 
side, thus exhibiting the signs of stimulation disharmony. 

In September, 1911, 1 observed spontaneous nystagmus to both sides 
in a case of bilateral erysipelas of the face following a cosmetic opera- 
tion upon the nose. By having the patient look first to the right, 
and then to the left, spontaneous nystagmus was made manifest in 
both directions. The nystagmus subsided with the disappearance of 
the erysipelas. 

Characteristics of Induced Nystagmus by Turning. — In making the turn- 
ing test it is necessary to differentiate between three types of expres- 
sion of induced nystagmus, namely, (a) induced primary nystagmus, 
(b) induced after-nystagmus, and (c) induced after-after-nystagmus. 

(a) Induced primary nystagmus, by the turning test, is the nystagmus 
which occurs during the turning, and is toward the direction of the 
turnings. (It is not practicable to observe nystagmus during the 
turnings, hence the induced after-nystagmus is observed instead.) 

(b) Induced after-nystagmus, by the turning test, is the nystagmus 
which occurs after the turnings cease, and is in the opposite direction 
to the primarv nvstagmus, or opposite to the direction of the turnings. 
(Plates XIX, "XX, and XXV.) 

(c) Induced afler-after-nysiagmus, by the turning test, is the nystag- 
mus which sometimes occurs when the after-nystagmus ceases, and 



874 THE EAR 

is in the same direction as the primary induced nystagmus, that is, 
toward the direction of the turnings, though weaker than the primary 
nystagmus. Induced after-after-nystagmus occurs after a prolonged 
turning test, and is explained as a phenomenon of fatigue from over- 
stimulation. Induced vestibular nystagmus may be horizontal, rota- 
tory, oblique, vertical, or combined horizontal and rotatory. 

Characteristics of Induced Caloric Nystagmus. — Caloric nystagmus is 
always rotatory and in the plane of the canal stimulated. By the cold 
caloric test the nystagmus is simple rotatory and is symbolized thus 
^*. By the warm caloric test it is combined rotatory and horizontal 
and is symbolized thus QJ . 

Characteristics of Induced Fistula Nystagmus. — Nystagmus by com- 
pression, in fistula of the labyrinth, may be horizontal or rotatory, 
according to the location of the fistula. If it is in the external limb 
of the horizontal canal the nystagmus will be horizontal and to the 
same side, and is symbolized thus — * . If the fistula is in the oval 
window the nystagmus will be horizontal and to the opposite side. If 
it is in the external arm of the superior canal it will be rotatory and 
to the same side, and is symbolized thus ^-* . 

Characteristics of Induced Galvanic Nystagmus. — Induced galvanic 
nystagmus is always rotatory. Galvanic nystagmus unlike any other 
induced nystagmus, may be induced even when the labyrinth and its 
cristse are totally destroyed through stimulation of the vestibular 
nerve and Deiters' nucleus. All types of induced vestibular nystagmus 
have a slow (vestibular element) and a quick (cortical element) com- 
ponent. All types of induced vestibular nystagmus endure from a few 
seconds to sixty seconds. Spontaneous vestibular nystagmus endures 
for from a few minutes to three weeks, gradually diminishing in inten- 
sity. 

Laws of Universal Application. — There are four laws of general 
application, first announced by Fleurens, Ewald, Hoegyes, and Neu- 
mann respectively. 

Fleurens' Law. — The movement of the eyes is in the plane of the 
canals subjected to stimulation. When the crista? of the horizontal 
canals are stimulated the eye movements are in the horizontal plane; 
when those of the superior (frontal) canals are stimulated, the move- 
ments of the eyes are in the frontal plane, that is, the eyes rotate upon 
their pupillary axes; when those of the posterior (oblique) canals are 
stimulated, the eye movements are in the vertical or saggital plane; 
and when the horizontal and superior canals are simultaneously stimu- 
lated there is a combined horizontal and rotatory nystagmatic move- 
ment of the eyes in the corresponding planes, and in the same direction; 
that is, the horizontal and rotatory nystagmus are in the same direc- 
tion either to the right or to the left. When one superior canal, and 
the opposite posterior canal, are simultaneously stimulated the induced 
nystagmus is oblique in direction and is symbolized thus / . 

Hoegyes' Law. — Each centrum (right and left) controls the adductor 
muscle of the same side and the abductor of the opposite side, respec- 



THE LABYRINTH 875 

tively. For example, the right centrum, Deiters' nucleus, controls 
the adductor of the same side, and the abductor of the opposite or 
left centrum controls the adductor of the same side, and the abductor 
of the opposite or right side, thus producing conjugate movements 
of the eyes to the right (slow component). Since the publication of 
Hoegyes' law it has been determined that, while under ordinary con- 
ditions the law is applicable, it does not express the whole truth. We 
now believe that each crista is a double end-organ and that each half 
emits nervous impulses antagonistic to the other half. The impulses 
from one half, however, are twice as strong as those given off from the 
opposite half. The stronger half of the crista determines the dictum 
of Hoegyes' law, the weaker half of the crista being a negligible quantity 
in the turning test. 

Neumann's Law. — Imagine the right and left horizontal, and the 
right and left superior canals, respectively, united at their non-am- 
pullated ends, thus forming two half-circles, with their ampullae at 
the ends of the half-circles, and the turning-point midway between the 
ampulla? of each pair of canals, and you have a visualized image of 
the direction of the flow of endolymph through each pair of canals. 
The head should be inclined 90 degrees either forward or backward 
in testing the superior canals (Plate XIX). This law does not apply 
in testing the posterior vertical (oblique) canals, as they do not lie in 
the same plane. Their relation to each other is as the two arms of 
the letter V. When the crista? of these canals are simultaneously 
stimulated, the movements of the eyes will be the mean between the 
angles of the two canals, that is, vertical; hence, when they are simul- 
taneously stimulated the nystagmus is vertical, and is symbolized 
thus T . The right superior and left posterior canals lie in the same 
plane, i. e., the oblique, and when they are simultaneously stimulated 
the nystagmus is in the oblique plane. This is also true of the left supe- 
rior and the right posterior canals. To visualize the relationship of the 
horizontal canals, clasp the hands behind the head and extend the elbows 
forward. The elbows correspond to the ampulla?, while the clasped hands 
correspond to the suppositious, united non-ampullated ends of the two 
horizontal canals. To visualize the superior canals clasp the hands 
over the vertex of the head, and allow the elbows to hang by either 
side of the face. The elbows correspond to the ampulla? of the superior 
canals, and the clasped hands to the suppositious, united non-ampul- 
lated ends of the canals. 

Ewald's Law. — The greater physiological impulses are produced in 
the horizontal canal by the movement or impact of the endolymph 
from the smooth or non-ampullated end of the canal, toward the 
ampulla? and utricles; whereas, the stronger physiological impulses 
from the crista of the superior and posterior canals are produced by 
a flow of endolymph in the reverse direction, i. e. 3 from the utricles 
through the ampulla? to the smooth or non-ampullated ends of the 
canals. 



876 THE EAR 

The Cristae AmpuUares. — Each crista ampullaris is a double end- 
organ of the vestibular nerve, the hair cells constituting the specialized 
nerve endings. The crista is a ridge-like eminence extending trans- 
versely across the ampulla and is surmounted by hair cells on each 
side of the ridge. Enveloping the hairs is a delicate gelatinous sub- 
stance called the cupola (see Plates XIX to XXVIII). The hair cells 
on the utricular half of the crista emanate impulses to certain muscles 
of the eyes, body, and extremities; while those on the other, or canal 
half of the cristae, emanate impulses to the opposing groups of muscles, 
of the eyes, body, and extremities (see Plates XIX to XXVIII). The 
two halves of each crista are therefore antagonists. The nerve fibers 
emanating from one half of the crista are apparently more numerous 
than those from the other half, or, at least, the impulses emanating 
from one half or side of the crista, are more than twice as strong as 
those emanating from the other side. That is, the canal half of the 
crista of the horizontal canal gives off impulses about twice as strong as 
those given off by the utricular half of the crista; whereas, in the supe- 
rior and posterior canals the stronger impulses arise from the utricular 
halves of the cristae, and the weaker impulses from the canal halves 
of the cristae. The utricular half of the crista of the left horizontal 
canal, and the canal half of the crista of the right horizontal canal 
act in unison in pulling the eyes (slow component) to the left. 

In each canal the greater reaction follows the stimulations of those 
hair cells which cause nystagmus to the same side or which cause the 
slow component to the opposite side. To visualize the relative strength 
of the impulses given off the cristae, two lines are used in the plates 
accompanying the text to represent the nervous tracts from the stronger 
half of each crista, and one line to represent the nervous paths from the 
weaker half of each crista. 

The nerve fibers arising from the utricular half of the crista of the 
right labyrinth go to the same muscles as those arising from the canal 
half of the left labyrinth. Whereas, the nerve fibers arising from the 
utricular half of the crista of the left labyrinth go to the same muscles 
as those arising from the canal half of the corresponding crista of the 
right labyrinth (Plates XIX to XXVIII). The utricular half of a 
crista of the right labyrinth, and the canal half of the corresponding 
crista of the left labyrinth, therefore, act in unison. 

In the turning test to the right, the flow of endolymph (after the 
turnings have ceased) is to the right, and the impact of endolymph 
is against the utricular half of the crista of the horizontal canal of the 
right labyrinth, and against the canal half of the crista of the horizontal 
canal of the left labyrinth (Plate XX). A weak impulse is therefore 
emitted from the right labyrinth, and a stronger one from the left 
labyrinth, which conjointly pull the eyes (slow component) to the 
right. The reverse movement of the eyes is induced when the patient 
is turned to the left. 

It appears, therefore, that two impulses may be excited in a given 
crista in labyrinth disease, and that they may be evoked in making 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 877 

the various physiological tests in disease and health. Through the 
interaction of these impulses and the cortical reflex impulses, nystag- 
mus is produced. In acute non-destructive congestion of the labyrinth, 
we must think of both halves of a given crista as being in a state of 
stimulation. For example, in congestion of the labyrinth due to acute 
otitis media (right ear) both halves of the crista of the right horizontal 
canal are stimulated. The canal half of the crista, giving off the stronger 
impulses, turns the eyes (slow component) to the left, while the utricular 
half of the stimulated crista tends to pull the eyes in the opposite 
direction, or to the right. The two halves of the crista are antagonists, 
but the canal half, giving off the stronger impulses, determines the 
direction of the slow movement of the nystagmus. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 



Fig. 486 



The Turning Test. — This test is made by placing the patient in a 
revolving chair (Fig. 486) and turning him ten times, either to the 
right or to the left. If the turnings are made with the head erect, 
only the cristse of the horizontal canals are 
stimulated, and a horizontal nystagmus 
results. If the head is inclined 90 degrees, 
either forward or backward, only the crista? 
of the superior canals are stimulated, and 
rotatory nystagmus results. If the head 
is inclined 45 degrees to either shoulder, one 
of the posterior vertical and one of the 
superior vertical canals are brought to the 
horizontal plane and an oblique nystagmus 
results. Each revolution of the patient should 
occupy from one to two seconds. 

In acute destruction of one labyrinth, with 
only partial compensation, from two to five 
turnings will induce nystagmus. This is ex- 
plained by the fact that there is only a par- 
tially established equality of extralabyrinth 
tonus; hence, the slight added stimulus 
caused by a few turnings is sufficient to 
overcome the existing fragmentary balance, 
and nystagmus results. As heretofore ex- 
plained, the early compensation is chiefly 
extralabyrinthine; that is, in the cerebellar 
centres. Neurasthenic cases, without laby- 
rinth disease are more susceptible to the turning test than non- 
neurasthenic ones; hence, in such cases less than ten turnings may 
produce maximum nystagmus when both labyrinths are normal. The 
absence of other signs of ear disease would readily differentiate these 
cases from labyrinth disease. 




Revolving chair used 
turning test. 



878 THE EAR 

Another fact that should be constantly held in mind in making all 
tests for pathological processes in the vestibular apparatus is, that the 
irritability of the diseased organ is diminished or altogether lost, in (a) 
acute diffuse suppurative manifest, (b) diffuse latent suppurative laby- 
rinthitis, and in (c) acute diffuse serous labyrinthitis (temporarily). In 
serous labyrinthitis the vestibular and cochlear functions gradually 
return after the absorption of the serous exudate in the lymph spaces. 
Formerly it was taught that increased irritability of the diseased 
vestibular apparatus was a constant factor, whereas, as I have 
already said, it may be increased in certain diseases, as in congestion 
of the labyrinth attending acute otitis media and in circumscribed 
labyrinthitis, but becomes diminished, or altogether lost, in acute, 
diffuse, suppurative, and serous labyrinthitis. In diffuse mani- 
fest and latent suppurative labyrinthitis the irritability of the 
vestibular apparatus is always permanently lost as the labyrinth 
is destroyed. 

The Rationale of the Turning Test. — As previously stated, each crista 
ampullaris is a double end-organ of the vestibular nerve, and its phys- 
iological activity is increased by stimulation from the impact of the 



PLATE XX 

Diagrammatic Illustration of the Nervous Connections of the Horizontal Semicircular 
Canals with the Eyes; and the Reaction Induced after Turnings to the Right Have 
Ceased. 

L, left eye; R, right eye; L.C.C., left cortical centre; R.C.C., right cortical 
centre; 777, nucleus of the third cranial nerve; L.VI, nucleus of sixth cranial nerve; 
R.VI, nucleus of right sixth cranial nerve; D.N., Deiters' nucleus; V.N., vestibu- 
lar nucleus; L.U., left utriculus; R.U., right utriculus; L.C.A., left crista ampul- 
laris; R.C.A., right crista ampullaris; — indicates the half of the crista giving off 
the weaker nervous impulses; + indicates the strong half of the crista; L.H.C., 
the left horizontal semicircular canal; R.H.C., the^right horizontal semicircular 
canal. Turning to the right is in the direction of the movements of the hands of 
a watch placed face upward. The blue arrows indicate the direction of the flow 
of endolymph during the turnings (primary flow). The red arrows in the canals 
indicate the direction of the flow of endolymph in the canals after the turnings have 
ceased (after-flow). During the turnings to the right the flow of endolymph (primary 
flow) is opposite to the direction of the turnings, or to the left, and the impact of 
this endolymph is against the canal half (+) of the right crista, and against the 
utricular half ( — ) of the left crista. The impulses thus excited turn the eyes to the 
left (slow component) and the cortical correction to the right immediately follows. 
Turning to the right therefore produces primary nystagmus to same side or to the 
right. The impact of the after-flow of endolymph in the left canal is against the 
hair cells of the half of the crista giving off the stronger ( + ) nervous impulses, 
whereas in the right canal it is against the weaker half of the crista ( — ). By tracing 
the red lines from each crista, through Deiters' nuclei (D.N., D.N.) and the right 
occulomotor neuclei (777, VI. R.) to the abductor muscles of the right eye and the 
adductor muscles of the left eye, an idea is formed of the nervous mechanism required 
to produce the conjugate slow movement of the after-nystagmus. The slow move- 
ment is to the right or in the direction of the turnings. A corrective cortical impulse 
is immediately liberated in the left cortical centre (L.C.C.) which is transmitted 
through the left third and sixth occulomotor nuclei (1II.L., VI.L.) to the adductor 
muscles of the right eye and to the abductors of the left eye, thereby producing a 
quick conjugate movement of both eyes to the left (quick component of the nystag- 
mus). The after-nystagmus is horizontal in the plane of the canals stimulated, 
and is to the left or opposite to the direction of the turnings. It is symbolized 
thus, — d. 



PLATE XX 



PRIMARY NYSTAGMUS TO THE RIGHT 

> > r 

AFTER NYSTAGMUS TO THE LEFT 

I* ' 



L.C.C. 



R.C.C. 




NORMAL 10 _ 
POTENTIALITIES^' ^^ 
INCREASED TO 20 



NORMAL 5 
POTENTIALITIES 
INCREASED TO 10 



T0T *L INCKE*^ 

Physiological Nystagmus by the Turning Test. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 879 

endolymph current against it. In the turning test the crista? of both 
horizontal canals are stimulated, one giving off impulses twice as 
strong as the other; that is, in one canal, the canal aspect of 
the crista, the side of the greater physiological activity is stimu- 
lated, and gives off impulses of, say 20 potentialities, and the utricu- 
lar aspect of the other crista, side of lesser physiological activity, is 
stimulated, and gives off an impulse of 10 potentialities. As the two 
cristas act in unison, they cause the slow component of the nystagmus 
(Plate XX). 

In the horizontal canals, the head erect, the turnings to the right, 
the flow of endolymph at the beginning of the turnings is in the oppo- 
site direction to the turnings, as the fluid lags behind, according to 
the law of inertia. At the beginning of the turnings to the right the 
fluid in the right horizontal canal flows from the canal through the 
ampulla to the utricle. In the left canal the impact of the current is 
against the utricular aspect of the cupola, the side giving off the lesser 
physiological impulses. The halves of the respective crista stimulated 
act in unison, the right crista emitting the greater impulse (controlling 
factor), and the left the lesser impulse (complimentary factor), the 
eyes are turned to the left (slow component). This liberates the reflex 
from the cortical centre (Plate XX, L.C.C.), which gives rise to the 
quick conjugate movement of the eyes to the right. It is, however, 
not practical to observe the primary nystagmus which occurs during 
turning, hence in practice the after-nystagmus is observed instead. 
The after-nystagmus is in the reverse direction to the primary induced 
nystagmus and is produced by the change in the direction of the 
flow or impact of endolymph, when the turnings are suddenly stopped. 
At the beginning of the turnings the endolymph lags behind the 
walls of the canals, or flows in the opposite direction to the turnings, 
but after a few seconds it becomes stationary in the canals, and 
when the turnings suddenly cease, it flows in the direction of the turn- 
ings (Fig. 487, Plate XX). The after-flow of endolymph is therefore 
to the right, when the turnings have been to the right, and vice versa, 
when to the left. 

In the right horizontal canal the fluid (when the turnings have 
ceased) flows from the utricle toward the canal, thus stimulating the 
hair cells of the crista giving off the weaker impulses. In the left 
canal the fluid flows from the canal toward the utricle, stimulating 
the hair cells of the crista on the side giving off the stronger impulses. 
The combined impulses from the two cristas acting in unison cause 
the slow movement of the nystagmus to the right, and the quick com- 
ponent to the left immediately follows (Plate XX). If, before the turn- 
ings, the potentiality of the canal half of the left crista was 10, and 
the utricular half of the right crista was 5, immediately after the 
turnings stop, the potentiality pull or impulse in the canal half of the 
left was increased, say 10 potentialities, while in the utricular half 
of the right crista it was increased 5 potentialities, the combined 
increase in the strength of the impulses is 15 potentialities, which 



880 THE EAR 

determines the slow component of the after-nystagmus to the right 
(Plate XX). 

The slow component of the after-nystagmus is always toward the 
same side as the direction of turning, while the quick component is 
toward the opposite side. 

In disease of the labyrinth the same principles apply as in the normal 
labyrinth, though there is some variation in the expression of the 
nystagmus; that is, the duration and the amplitude of the excursions 
may be somewhat modified, and fewer turnings may be required to 
induce the nystagmus, especially if complete extralabyrinthine com- 
pensation has not occurred. The amplitude and duration of the 
excursions is somewhat proportionate to the degree of discrepancy 
existing in the tonus (either normal or compensating tonus) of the two 
vestibular apparatuses. They are also in close relationship to the 
recentness and suddenness of the disturbed equilibrium. 

In testing the superior canals, Neumann's law in reference to imagin- 
ary union of the smooth or non-ampullated ends of the superior canals, 
thus making a half-circle in the frontal plane, with the ampullae at the 
ends of the half-circle, holds true, as in the horizontal canals. Hoegyes' 
law in reference to the centrum of the right and left sides, respectively, 
controlling the adductor muscles of the eye of the same side, and the 
abductors of the opposite side, also applies to these canals. Fleurens' 
law is also exemplified in this experiment, i. e., the nystagmus is in 
the plane of the canals subjected to stimulation, rotatory on the pupil- 
lary axes. To test the superior canals by the turning test, the head 
must be inclined 90 degrees, either forward or backward, to bring 
the canals into the horizontal plane. The after-nystagmus induced 
by turning to the right, with the head forward, is rotatory, and to 
the right. For an explanation of the difference in the direction of the 
induced nystagmus consult Plate XIX, in which it is shown that 
when the head is inclined forward, the crista of the left canal receives 
the impact of the after-flow on its utricular side, the side giving off 
the stronger physiological impulses, while the right crista receives the 
impact on the canal half of the crista, which gives off the weaker 
nervous impulses. The two cristas act in unison in producing the 
rotatory slow eye movement to the right, and the cortical correction to 
the left follows; hence, the after-nystagmus is rotatory and to the left. 
Plate XIX shows that when the head is inclined 90 degrees back- 
ward, and the turnings are to the right, and suddenly stopped, the 
crista of the right side is impacted on the side giving off the stronger 
physiological impulses (+), while the left is impacted on the side 
giving off the weaker impulses ( — ); hence, the right crista controls, 
though both act in unison, and the after-nystagmus is rotatory to 
the right. 

A simpler statement is that (a) when the head is inclined forward 
the after-nystagmus is opposite to the direction of the turnings, and 
(b) when the head is inclined backward the after-nystagmus is in 
the direction of turnings. It is rotatory in the frontal plane in each 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 881 

instance. In accordance with Fleurens' law, namely that the nystag- 
matic movements of the eyes are in the plane of the canals stimu- 
lated. 

According to Barany the average duration of induced nystagmus 
from the horizontal canals is forty seconds, and from the superior 
canals, twenty-six seconds. 

The Caloric Tests. — Thg caloric tests are, generally speaking, more 
reliable than the others, though when certain conditions are present, 
as granulations, ceruminous plugs, polypi, atresia of the meatus, or 
large granulations, the caloric test cannot be successfully performed. 
Marked elevation of temperature may, for obvious reasons, also inter- 
fere with the reaction. When none of these conditions is present the 
caloric test is, perhaps, the most delicate, and conveys the most signifi- 
cant information of the various tests at our command. The reaction 
depends upon projecting a stream of water, of either a considerably 
higher or a lower temperature than that of the body, against the drum- 
head or the promontorium, when perforation of the membrana tympan- 
um is present. Colder, rather than warmer, than the body temperature 
is preferable, as the patient often does not tolerate water of high enough 
temperature to ensure a reaction, even when functional activity is 
present. The reaction is dependent upon either raising or lowering the 
temperature of the endolymph in the outer and more exposed portion 
of the utriculus, and the membranous horizontal and superior canals. 
The ampullae of these canals are near together, just above the oval 
window. The nystagmus is always rotatory, though it may be combined 
rotatory and horizontal, the rotatory element always being the stronger. 
The posterior canal is too deeply situated to be influenced by either 
cold or heat; hence, it cannot be tested for the caloric reaction. The 
caloric, like the turning test, depends upon establishing a circulation of 
the endolymph through the utriculus and membranous semicircular 
canals, or in the case of the cold caloric test, upon inhibition of the 
nervous impulses in the tested ear. The cold test induces a flow of 
endolymph against the weaker half of the crista of the superior canal 
(Plate XIX) and the nystagmus should be weaker than that produced 
by the warm test. As a matter of fact, it produces a stronger reaction, 
which may be explained upon the theory of inhibition. The circulating 
fluid being impacted against the cupola of the crista ampullaris, 
stimulates the hair cells upon the impacted side, and this increases 
the impulse, physiological pull, or potentiality, as explained under 
Turning Test. 

The caloric test has been regarded as both a qualitative and a quanti- 
tative test. G. W. MacKenzie, however, says that it is unreliable as 
a quantitative test, as it is impossible in most cases to have the same 
conditions present in both ears. That is, in one ear the drum-head is 
intact, and in the other perforated or absent, and if present in both ears, 
one may be thicker than the other. Inspissated pus or mucus may be 
present in one ear and absent in the other. Polypi or granulations may 
be present in one ear only; cerumen may be present in one oar end absent 

56 



882 



THE EAR 



or of smaller quantity in the other; one meatus may be smaller or 
partially closed by atresia; the affected or inflamed ear has a higher 
temperature than the uninflamed ear, etc. All these conditions would 
interfere with the equality of the tests of the two ears, and as one or 



Fig. 487 



Fig. 488 




Showing (a) the caloric test (warm water), right ear, 
producing nystagmus, the quick component of which is 
to the affected or tested side; (b) the negative galvanic 
current ( — ) applied in front of the right ear, producing 
nystagmus to the same side; (c) turning the patient 
to the right with the quick component of the primary 
nystagmus (during turning) to the right. 



Schematic drawing, showing the influ- 
ence of hot water applied to the right 
middle ear: u, the utriculus. As the 
endolymph in the utriculus is warmed, it 
rises through the anterior vertical semi- 
circular canal, and thus stimulates the 
crista ampullaris of this canal upon 
the ( + ) side of greatest physiological 
activity. As the horizontal canal is on a 
lower level than the utriculus, the endo- 
lymph remains stationary. The result 
of warm irrigations is therefore limited 
to rotary nystagmus to the right. 



more of them is present in nearly every individual, especially if one ear 
is diseased, MacKenzie claims the caloric test is of little or no value in 
estimating the degree of destruction present in the affected ear. 

On the other hand Barany, Neumann, Alexander, and most other 
writers and observers, regard the caloric test as one of the best quan- 
titative tests at our command, though they call attention to the 
above conditions as factors which may render it of no value as a 
quantitative procedure. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 883 

The Caloric Test with Cold Water. — This test is performed by stimu- 
lating the vestibular apparatus with a small stream of water at about 



Fig. 489 



Fig. 490 





Showing (a) caloric test (cold water), right ear, with 
nystagmus to the left; (b) the positive galvanic electrode 
( + ) in front of the right ear, causing nystagmus to the 
left; (c) turning the patient to the left, causing primary 
nystagmus to the left. The total result is a combined hori- 
zontal and rotary nystagmus to the left. 




COLD 
WATER 



Schematic drawing, showing the 
influence of cold water applied to 
the right middle ear: u, the utric- 
ulus. As the endolymph in the 
anterior vertical and horizontal 
canals and the utriculus is cooled, 
it seeks the lowest level, hence the 
movement of the endolymph in the 
anterior vertical canal is from the 
ampulla to the utriculus. The crista 
ampullaris is thus stimulated upon 
the side of least physiological activ- 
ity and causes rotary nystagmus 
to the left. The endolymph also 
flows downward from the utriculus 
through the ampulla of the hori- 
zontal canal, and • stimulates the 
crista ampullaris upon its side of 
least physiological irritability and 
produces horizontal nystagmus to 
the left. The total result of cold- 
water irrigation is, therefore, a com- 
bined horizontal and rotary nystag- 
mus to the left or opposite side. 



78° F., though in some cases water of a lower temperature will be 
required to induce nystagmus. A fountain syringe, elevated slightly 
higher than the head of the patient, may be used in making this test 
(Figs. 489 and 490), or a Politzer bag with a suitable tip may be used. 
Force is not necessary, as the only object of the procedure is to cool 
the outer wall of the utriculus and membranous canals, thus inducing 



884 THE EAR 

a circulation of the endolymph through them. According to a well- 
known physical law, when that portion of water or other fluid contained 
in a vessel is cooled, it sinks or flows downward, thus creating a circu- 
lation of the fluid within the vessel. As the external limb of the superior 
canal and external wall of the utriculus are cooled, there is a downward 
flow of the endolymph, which causes an impact against the hair cells 
on the canal or weaker half of the crista ampullaris of the superior 
canal (Fig. 490). (See preceding paragraph for other explanation.) 
The potentiality of this half of the crista is thereby increased, while 
the crista of the superior canal of the opposite labyrinth remains 
unaffected. We will assume that before the test was applied each 
canal half of the crista had a potentiality or pull of 10, and that during 
and for several seconds after the test, the crista of the right or irri- 
gated labyrinth was decreased to 5 potentialities. The potentiality of 
the left crista being normal, greater than that of the right or tested 
ear, which is diminished to 5. The left crista having the greater 
potentiality, in accordance with Hoegyes' law, turns the eyes to the right 
(slow component), and the corrective quick component to the left 
immediately follows. The nystagmus being named after the direction 
of the quick component, it is said to be to the left, or to the opposite 
side, or away from the side being tested (Plates XIX and XXVII). 
And, in accordance with Fleurens' law, the nystagmus corresponds with 
the plane of the canal stimulated, i. e., it is rotatory, and in the frontal 
plane. The eyes rotate upon their pupillary axes. It should be said in 
addition that the Cold caloric test may produce a combined horizontal 
and rotatory nystagmus, because the endolymph may also flow back- 
ward through the horizontal canal, which is sometimes inclined slightly 
downward, a fact emphasized by Barany, Neumann, and J. R. Fletcher. 
This causes inhibition of the crista of the right horizontal canal. The 
response to the inhibition applied to the two canals is a weak horizontal 
and a stronger rotatory nystagmus, which is due to a stronger tonus 
in the left labyrinth. The total result is called a combined weak 
horizontal and a strong rotatory nystagmus (Figs. 489 and 490). 

According to Neumann a prolonged induced nystagmus may be 
established in cerebellar disease by irrigating the healthy side with 
cold water. This is known as Neumann's enduring nystagmus. The 
nystagmus induced by cold water in a normal ear, when there is no 
labyrinth or cerebellar disease, is of much shorter duration. The 
enduring nystagmus induced by the cold caloric test, applied to the 
normal side in cerebellar disease, is due to the fact that the spontaneous 
nystagmus of cerebellar origin is augmented by the inhibition following 
the cold caloric test. The cerebellar nystagmus is to the diseased 
side, and the induced cold caloric nystagmus caused by inhibiting 
the healthy side leaves the diseased side with a great preponderance 
of tonus, which results in the increased and prolonged or enduring 
nystagmus. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 885 

Fig. 491 




Ruttm's double irrigator for making a comparative test of both ears at the same time. 



886 



THE EAR 



Fig. 492 



The Caloric Test with Warm Water. — Water of about 120° F. should 
be used in making this test. It is applied in the same manner as cold 
water, and the reaction depends upon establishing a circulation of 
the endolymph. In this instance the temperature of the superficially 
exposed endolymph is elevated above that more deeply situated, and 
in consequence it rises through the ampulla and external arm of the 
superior membranous canal, thus stimulating the hair cells of the crista 
on its utricular half, the side giving off the stronger impulses (Figs. 
487 and 488). We will assume that before the test the potentiality 
or tonus of the utricular half of the crista of each superior canal was 
10, and that during the test it was increased to 20 in the tested (right) 
ear. This portion of the vestibular apparatus having a preponderance 
of potentiality or pull, turns the eyes away from the tested side, i. e., 
to the left (slow component), and the cortical correction immediately 
reverses the movement of the eyes (quick component) to the right, or 
side being tested. Briefly stated, the warm caloric test causes rotatory 
nystagmus to the same side. The crista of the horizontal canal is not 

affected. The result of the test is a rota- 
tory nystagmus to the same side (Plate 
XIX). 

In suspected double circumscribed or serous 
labyrinthitis it may become necessary to 
test both ears simultaneously to determine 
which side retains the more functional 
activity. Ruttin's double irrigator is 
used for this purpose (Figs. 491 and 
492). It consists of two ear specula? 
mounted with ball-and-socket joints upon 
a head-band. The irrigation tips being 
permanently fixed within the specula?. 
The head-band is adjusted to the patient's 
head, the specula? inserted in the meatuses, 
and the water turned on simultaneously 
into both meatuses. The same amount 
of water should flow into each ear, as if 
one receives more than the other in a given 
time, it will be more cooled and render 
the test of no value. Both labyrinths 
must be equally and simultaneously cooled. The water flowing from 
each should, therefore, be collected and measured as a check upon the 
accuracy of the experiment. If the amount of water flowing into each 
ear is equal in quantity and temperature, and flows against the ears 
within the same period of time, the more sensitive ear will be inhibited 
(cold caloric) first, that is, the nystagmus will be away from the more 
sensitive and more nearly normal ear toward the more affected ear. 

To avoid nausea and vomiting during the caloric test, have the 
patient look in the direction of the expected quick component, that is, 
to the opposite side when cold water is used, and to the same side 




Ruttin's double irrigator. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 887 



when warm water is used. This will induce nystagmus with the mini- 
mum of irrigation, as nystagmus is favored by looking in the direction 
of the quick component, and is suppressed by looking in the direc- 
tion of the slow component. Before applying the Ruttin's double 
caloric test, carefully inspect both ears to see if the physical conditions 
are about the same on both sides. If atresia of one meatus or polypi 
on one side is present, or a larger amount of heavy secretion is present 
in one ear than in the other, 

the accuracy of the test will FlG - 493 

be affected. 

If the caloric, or any other 
test, causes nausea and vomit- 
ing in a case upon which an 
operation is contemplated, 
the operation should be post- 
poned until the next day to 
allow the nystagmus and nau- 
sea to subside. 

When the tests are made in 
the office, great care should 
be taken to avoid inducing 
nausea and vomiting, as it 
may be several hours before 
the patient thus affected can 
be removed to his home. In 
using water of about 78° F., 
have the patient look tow T ard 
the opposite side, the direc- 
tion of the expected quick 
component, and watch for 
the first appearance of the 
nystagmus, and stop syring- 
ing when it appears. In 
making the qualitative test, it 
is only important to know if 
nystagmus can or cannot be 
induced ; that is, is the vestibu- 
lar apparatus functionating or 
dead? In making the quanti- 
tative test it is necessary to 
know how difficult it is to arouse the vestibular apparatus to func- 
tional activity. The intensity and duration of the nystagmus are 
also factors in the quantitative test. 

Clinical Significance of the Caloric Test. — In labyrinth disease the 
caloric test is used for two purposes, namely, (a) as a qualitative test 
to determine whether the labyrinth is responsive to stimulus or is 
irresponsive to it. If responsive to stimulation there is usually no 
immediate danger of the infection extending to the meninges or brain. 




The fistula test, causing irregular nystagmatic 
movements of the eyes. 



THE EAR 

If it is not responsive to the cold stimulus the infection of the meninges 
and brain could not be anticipated until such infection had actually 
occurred, as the labyrinth is dead, and cannot give rise to vestibular 
symptoms, as vertigo, nausea, vomiting, and ataxia. In such a case, 
with a recent vertiginous attack, followed by complete deafness and 
negative caloric and fistula tests, an immediate labyrinth operation 
may be advised to prevent the extension of the infectious process to 
the meninges and brain. 

(b) The second object of the caloric test in labyrinth disease is to 
make a quantitative test of the vestibular apparatus. The amount 
of cold water used, the time consumed in its application, and the 
duration of the induced nystagmus should be noted. If nystagmus 
is induced by a small amount of cold water, in a short time, and the 
nystagmus endures for nearly the normal number of seconds, the ves- 
tibular apparatus is but slightly affected and operation on the laby- 
rinth is strongly contra-indicated. If, however, it requires long irriga- 
tion to produce but slight nystagmus of short duration, the vestibular 
apparatus is nearly destroyed, and close watch and repeated tests 
should be made to determine whether the destruction is progressing. 
If so the attending otologist should be prepared to do a labyrinth 
operation should the indications arise. If the caloric test elicits no 
vestibular response the labyrinth is either inhibited, as in severe 
serous labyrinthitis, or is destroyed, as in acute diffuse manifest suppu- 
rative and latent suppurative labyrinthitis. In serous labyrinthitis 
operation is not indicated. If acute diffuse manifest or latent suppura- 
tive labyrinthitis is shown, an operation may be advised. The indica- 
tions are suggested in this connection to show the clinical value of the 
qualitative and quantitative tests. 

The Fistula Test. — The fistula test is usually made by compressing 
air within the external meatus with a Politzer bag fitted with a six- 
inch rubber tubing and an olive-shaped ear tip which is inserted 
into the meatus (Fig. 493). Either compression or suction may be 
used, though compression is usually practised. The nystagmus is 



PLATE XXI 

Diagrammatic Illustration of the Mechanism of Induced Fistula Nystagmus, the 
Fistula Being in the External Limb of the Horizontal Canal and Posterior to the Facial 
Ridge. 

The compression is applied at the fistula (/) which causes an endolymph current 
from the canal to the utricular — against the canal — half of the crista. This half when 
stimulated gives off nervous impulses twice as strong as those given off from the 
utricular half. The course of the impulses is indicated by the two blue lines to the 
abductor muscles of the left eye (L), and to the adductor muscles of the right eye 
(R). A slow conjugate movement of both eyes to the left results (slow component). 
The right cortical centre (C.C.) immediately gives off an impulse which traverses the 
right third and sixth oculomotor nuclei, from whence it is conveyed to the adductor 
of the left eye and the abductor muscle of the right eye, thereby inducing a quick 
conjugate movement of both eyes to the right. The nystagmus thus induced is 

horizontal, strong, and to the right, and is symbolized thus ~T ^r. It is 

. . J strong 

strong and more enduring because it emanated from the stronger half of the crista 
ampullaris. 



PLATE XXI 



SPONTANEOUS 

> > r 



COMPRESSION 




Fistula of Horizontal Canal, with Spontaneous and Induced 

Nystagmus. 



PLATE XXII 



SPONTANEOUS „ 

COMPRESSION 
< < 




Fistula of Oval Window, with Spontaneous and Induced 

Nystagmus. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 889 

usually to the same side (Plate XXI). As a fistula of the oval window 
or promontory is a more serious condition than fistula of the horizontal 
canal, it is of some interest to determine its location. Hence, when 
the induced nystagmus is to the opposite side the fistula is probably 
in the oval window, or somewhere anterior to the descending portion 
of the facial nerve, the region of greater danger. If the induced nystag- 
mus is to the same side, the fistula is probably situated in the horizontal 
canal posterior to the facial nerve, the region of lesser danger. If the 
fistula is over the promontorium and opens into the vestibule, the 
nystagmus is usually to the opposite side, as the flow of endolymph 
caused by compression is from the utricle through the ampulla to the 
smooth end of the horizontal canal, and the crista is stimulated on its 
utricular side, which pulls the eyes (slow component) to the same 
side, and the cortical reflex immediately following, pulls the eyes to 
the opposite side (quick component), thus constituting nystagmus 
to the opposite side (Plate XXII). Aspiration will reverse the direc- 
tion of the flow of endolymph, and the nystagmus will be reversed in 
direction. The location o ! the fistula does not absolutely determine 
the direction of the flow of endolymph, hence the nystagmus may be 
to the same or to the opposite side, regardless of the 'location of the 
fistula. 

If the fistula is in the external limb of the horizontal canal and the 
compression test is made, the flow of endolymph is from the canal 
through the ampulla to the utricle. The impact of the endolymph is 
against the canal half of the crista, which emits nervous impulses 
that traverse the path indicated by the blue lines shown in Plate 
XXI. In this illustration the right horizontal canal is fistulous, and 
the impulses arising in the canal half of the crista are transmitted 
to the right Deiters' nucleus, and thence to the left third and 
sixth oculomotor nuclei, and from there to the abductor muscles 
of the left eye, and the adductor muscles of the right eye. This 
induces a conjugate movement of both eyes to the left (slow 
component), a corrective cortical impulse is immediately excited in 
the right cortical centre which is transmitted to the right third and 



PLATE XXII 

Diagrammatic Illustration of the Mechanism of Induced Fistula Nystagmus in Fistula 
of the Oval Window. 

Compression is applied at/, a fistula at the oval window which communicates with 
the vestibule. This causes a flow of endolymph backward against the utricular or 
weaker half of the crista. The impulse aroused by the impact traverses the course 
indicated by the single red line (a) and finally reaches the adductors of the left eye 
and the abductors of the right eye, thereby inducing a slow conjugate movement 
of both eyes to the right (slow component). A corrective cortical impulse is imme- 
diately liberated in the left cortical centre (C.C.) and is transmitted to the third 
and sixth oculomotor nuclei (III C , VI C ) and thence to the adductors of the right 
eye and abductors of the left eye, thereby inducing a quick conjugate movement 
of both eyes to the left (quick component). The compression test applied to the 
right ear, with fistula anterior to thecrista, is followed by induced weak nystagmus 
to the left which is symbolized thus: ^-^ 1. 



890 THE EAR 

sixth oculomotor nuclei, and thence to the adductor muscles of the 
left eye and the abductor muscles of the right eye, thereby producing 
nystagmus to the right. In fistulous cases, in which the labyrinth is 
not destroyed, we are dealing with circumscribed labyrinthitis. These 
cases usually respond normally to the turning and the caloric tests. 
The clinical significance of the positive fistula reaction is that the 
vestibular apparatus is still functionating, and an operation is not 
indicated. The significance of a negative fistula test is nil, as a fistula 
may or may not be present. 

Hindrances to the Fistula Test. — The presence of cholesteatoma, 
cerumen, large polypi, atresia, or granulations may interfere with the 
application of this test, as either condition may block the fistula 
and prevent the action of the compressed air upon the portion of 
the membranous labyrinth exposed by the bony fistula. 

The caloric test is less reliable than the fistula test when the endo- 
lymph is coagulated. If, therefore, the caloric reaction is negative, 
and the fistula test positive, it may be taken as a sign that the endo- 
lymph is coagulated. It may be necessary to compress the bulb several 
times to induce nystagmus. 

Nystagmus induced by the fistula test is an indication of fistula, 
though the absence of nystagmus is not a sure sign that fistula is not 
present. When the reaction is present "fistula symptom" is said to 
be positive. The fistula test is negative when the labyrinth is totally 
destroyed, even though a large fistula is present. The bony fistula 
may be so small it cannot be seen at the time of the mastoid opera- 
tion, yet still be large enough to give rise to fistula symptoms upon 
compression. When present we say, fistula symptom is plus or positive; 
when absent we say, fistula symptom is minus or negative. 

The Clinical Significance of the Fistula Test. — The compression 
and aspiration tests are of diagnostic value under the following con- 
ditions: 

1. When there is a bony defect or fistula without involvement of 
the membranous labyrinth the fistula test is positive, i. e., nystagmus 
is induced. The caloric and turning tests also give normal positive 
reactions. The prognosis in these cases is good and the usual thera- 
peutic and surgical measures demanded for the cure of the middle- 
ear and mastoid disease are indicated. The labyrinth needs no other 
treatment. 

2. The spontaneous nystagmus of acute diffuse manifest suppurative 
labyrinthitis with fistula is not increased by the compression, as the 
labyrinth is totally destroyed. The spontaneous nystagmus present 
is due to the sudden loss of tonus in the destroyed labyrinth or, rather, 
to the sudden loss of equality of tonus between the. two labyrinths. 
The prognosis is grave, and the labyrinth may, and indeed often 
should, be operated as soon as all hearing is lost. 

3. In diffuse latent suppurative labyrinthitis (chronic stage of acute 
diffuse manifest suppurative labyrinthitis) the fistula test is sometimes 
positive in reaction. That is, the cochlea may be totally destroyed, 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 891 

while the vestibular apparatus is nearly, though not quite, destroyed. 
This is explained by the fact that the cochlear portion of the eighth 
cranial nerve is more easily destroyed by suppurative inflammation 
than the vestibular portion. The prognosis is grave in these cases. 
That is, there is always a probability of the infectious process extend- 
ing at some subsequent time to the meninges or cerebellum. Cere- 
bellar abscess often follows chronic diffuse latent suppurative laby- 
rinthitis. 

4. In circumscribed labyrinthitis without bony fistula, the fistula 
test is negative in reaction. Such cases should always be tested, 
because the absence of the fistula symptom is of great diagnostic and 
prognostic value. These cases are more favorable than those with 
fistula. 

The Galvanic Test. — According to J. R. Fletcher, the work done by 
Alexander, Neumann, Frey, Hammerschlag, and Barany, on nystag- 
mus by galvanization, is not conclusive. According to Neumann, 
galvanism may produce nystagmus when the labyrinth is totally 
destroyed, which, he says, is due to the direct galvanization of the 
vestibular nerve and centrum. The kathode (minus or negative pole) 
affects the nervous tissue more than the anode (the plus or positive 
pole) and induces nystagmus to the same side (Plate XXIII). 

According to Neumann, if there is no reaction from either the turning, 
caloric, or galvanic tests the centrum is destroyed. If only the laby- 
rinth is destroyed, and the vestibular nerve and centrum are normal, 
the turning and caloric tests will not produce nystagmus; whereas 
the galvanic test may produce it, as the electric current acts directly 
upon the vestibular nerve and centrum. 

Neumann regards Brunnung's theory, namely, that the kathode pro- 
duces a flow of endolymph in the canals by galvanism, as unproved and 
improbable, as he has shown that nystagmus is produced by galvanism 
when the labyrinth is completely destroyed. This he regards as being 
due to the galvanism of the vestibular nerve, or of Deiters' nucleus. 
Galvanic induced nystagmus is always rotatory and toward the 
kathode or away from the anode. 

Galvanism after a recent acute suppurative destruction of the 
labyrinth (diffuse manifest suppurative labyrinthitis) may cause 
marked induced nystagmus by direct action on the vestibular nerve. 
The response to galvanism gradually diminishes in intensity as the 
vestibular nerve degenerates, and finally, when the centrum is also 
completely degenerated, nystagmus can no longer be excited by it. 

Bipolar irritation with one electrode over each mastoid process 
requires from 2 to 5 m.a. of current, while the monopolar application 
with one electrode to the mastoid, the other in the hand, requires 
20 to 25 m.a. of current to produce nystagmus in normal cases. 

The quick component of induced galvanic nystagmus is always 
toward the kathode (negative pole), whether the applications are 
bipolar or monopolar. If the kathode is applied to the right mastoid 
process, the nystagmus will be to the right. If both the kathodal 



892 THE EAR 

and anodal electrodes are held in the hands, both ears being normal, 
there will be no nystagmus. If, however, either labyrinth is diseased 
but not totally destroyed, and both the kathodal and anodal electrodes 
are held in the hands, the nystagmus will be toward the healthy side, 
as this is the more sensitive of the two, has the greater tonus, and pulls 
the eyes to the opposite or diseased side (slow component), after which 
the quick component of the induced nystagmus occurs to the same or 
healthy side. The galvanic test alone should not be used to determine 
whether the labyrinth is still functionating, as it will induce reaction 
when the labyrinth is totally destroyed, provided the vestibular nerve 
and centrum are intact. 

The kathode applied in front of the right ear produces a stimulation 
of the crista ampullares and Deiters' nucleus on that side, and causes 
a slow conjugate movement of the eyes to the left, and the cortical 
correction to the right (same side) immediately follows (Plates XXIII 
and XXIV). That is, before the kathode current is applied the tonus 
impulses emanating from each labyrinth is equal. The kathode stimu- 
lation increases the tonus on the right side, whereas it remains the same 
on the left side. The impulses, therefore, were stronger on the right, 
and according to Hoegyes' law, the eyes were turned to the left or 
opposite side (slow component of the nystagmus), and the cortical 
correction immediately occurs, and the eyes are turned to the right 
side (quick component of the nystagmus). 

The anode applied to the right ear produces an inhibition of the 
crista? and Deiters' nucleus on that side, and causes a slow conjugate 
movement of the eyes to the right, and the cortical correction to the 
left (opposite) side immediately follows (Plate XXIV). 

That is, before the anode is applied to the right ear the tonus impulses 
are the same in both labyrinths and centrums. After the anodal 
current is applied to the right ear, the tonus impulses are inhibited or 
diminished in the right labyrinth and centrum, leaving a preponder- 
ance of tonus in the left labyrinth and centrum, which, according to 
Hoegyes' law, turns the eyes to the right (slow component) and the 



PLATE XXIII 

Diagrammatic Illustration of the Mechanism of Induced Kathodal Galvanic Nystag- 
mus. 

The kathode or negative pole of the battery is applied to the right ear, the ves- 
tibular apparatus of which is stimulated to greater physiological activity. The 
increased impuless are transmitted through the paths (ob, blue lines) to Deiters' 
nucleus, and thence to the third and sixth oculomotor centres of the left side (III, 
VI), and finally to the adductor muscle of the right eye, and to the abductor muscle 
of the left eye, thereby causing a slow conjugate movement of both eyes to the 
left (slow component). A corrective cortical impulse immediately arises in the 
right cortical centre (R.C.C.), and is transmitted to the right third and sixth nuclei, 
and thence to the abductor muscles of the right eye, and to the adductor muscles 
of the left eye, thereby producing a quick conjugate movement of both eyes to 
the right (quick component of the nystagmus). The nystagmus is rotatory and 
to the right or same side, and is symbolized thus : /~^ r. 

The kathode induces nystagmus to the same side. 

The anode induces nystagmus to the opposite side. 



PLATE XXIII 



SLOW 



KATHODE PRODUCES 
NYSTAGMUS TO 
THE SAME SIDE. 




n-XB 



Kathodal Induced Nystagmus. 



PLATE XXIV 



r\i 




THE ANODE 
PRODUCES 
NYSTAGMUS TO 
OPPOSITE SIDE 



Anodal Nystagmus to the Opposite Side. 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 893 

cortical impulse immediately follows and turns the eyes in the opposite 
direction to the left (quick component). 

Clinical Significance of the Galvanic Test. — The galvanic test is 
generally regarded as of less clinical importance than the other tests, 
as nystagmus produced by it may not be due to stimulation of the 
labyrinth, but may be due to stimulation of the vestibular nerve and 
Deiters' nucleus. Inasmuch as the nystagmus may be due to stimu- 
lation of the vestibular portion of the labyrinth or the vestibular nerve 
and Deiters' nucleus, the test is of doubtful diagnostic value in deter- 
mining the functional activity of the cristas. When, however, the 
labyrinth is known to be totally destroyed the galvanic test is of great 
value in estimating the degree of extralabyrinthine degeneration. 
By this test the prognosis of the degeneration of the vestibular nerve 
and Deiters' nucleus may be estimated from time to time until all re- 
sponse is abolished, an occurrence signalizing the total degeneration of 
the vestibular nerve and the central nuclei associated in function with 
it. These nuclei are Deiters', Bechterew's, and the angular nucleus. 

Some Clinical Problems. — I will attempt to suggest the clinical 
significance of the various vestibular tests by reciting the clinical 
phenomena of a hypothetical case. The ultimate purpose of all clinical 
and laboratory observations is the amelioration and cure of disease. 
This is true of labyrinth disease. In the following paragraphs will be 
found the essential elements for illustrating the clinical application of 
the various vestibular tests. 

(a) When the labyrinth of the affected ear is totally destroyed, 
that is, when there is a total and permanent deafness in the affected 
ear, and all vestibular (static) function is also lost, there is therefore 
no hope of restoring either the hearing or the static function, insofar 
as this labyrinth is concerned. The static function is, however, rapidly 
adjusted in the extralabyrinthine nervous mechanism of the cere- 
bellum, and need give the clinician no concern. The deafness being 
forever lost, and the static function being automatically adjusted, 
neither requires treatment. 

(b) If the patient still suffers from chronic otorrhea and mastoiditis 
with recurrent attacks of the same, he needs a radical mastoid 
operation. 

PLATE XXIV 

Diagrammatic Illustration of the Mechanism of Anodal Galvanic Nystagmus. 

When the anode or positive pole is applied to the right ear (ANODE) the im- 
pulses are suppressed in that ear, while they are unaffected in the opposite or left ear. 
The impulses from the left ear having a stronger tonus or pull, turn the eyes to 
the right — trace red lines to abductors of the right eye (R) and to the adductors of 
the left eye (L) — thus producing the slow movement or component of the nystag- 
mus. A corrective cortical impulse is immediately liberated in the left cortical 
centre (C.C.), which is transmitted through the third and sixth occulomotor centres 
(III, VI) to adductors of the right eye (R) and the abductors of the left eye (L), 
which causes a quick conjugate movement of both eyes to the left (quick compo- 
nent of the nystagmus). The nystagmus is rotatory (as all the crista^ are stimu- 
lated) and to the left, and is symbolized thus: ^-^ 1. The anode produces nystag- 
mus to the opposite side. The kathode produces nystagmus to the same side. 



894 THE EAR 

(c) There also remains another condition of grave clinical significance, 
namely, chronic latent suppurative labyrinthitis. There are, however, 
no manifest symptoms of the disease, as both the cochlea and vestibular 
apparatuses are totally destroyed, and rendered functionless, and extra- 
labyrinthine compensation has occurred and nystagmus is no longer 
present. The infection in the labyrinth canals may still be present 
just as truly as it was when the symptoms were manifest, and compen- 
sation had not occurred. The infection may therefore "silently" 
extend to the meninges and brain and cause meningitis or cerebellar 
abscess. The mortality of meningitis is over 95 per cent., while that 
of cerebellar abscess is more than 75 per cent, under operation. The 
great problem presented in these cases is the prevention of meningitis 
and cerebellar abscess, for, if either of these pathological conditions 
develops, the patient's life is in the gravest danger. The relief of the 
chronic otorrhea and mastoiditis is of secondary importance, though 
from the patient's point of view, it may be of the first importance. 
It becomes the province of the attending otologist to ascertain all 
the facts in relation to each case, and to advise the patient or his friends 
as to their true significance, and the course of treatment required to 
insure the most favorable result. 

The clinical problems therefore become resolved into the following 
alternatives: (1) The radical mastoid operation to cure the mastoiditis 
and chronic otorrhea. If this is done without reference to the labyrinth, 
what may be the outcome? Clinical experience has shown that if, 
after the complete destruction of the labyrinth, the mastoid operation 
is performed without the radical exenteration of the labyrinth at the 
same time, the infection within the labyrinth often subsequently 
extends to the meninges (diffuse suppurative meningitis, leptomenin- 
gitis) and results in death. Clinical observation has also shown that 
if in such cases the labyrinth is operated, life expectancy is increased. 
I have seen a few cases not operated, or which had only a mastoid 
operation, subsequently develop meningitis or cerebellar abscess. 

Clinical observation also shows that if the radical mastoid operation 
and labyrinth operation are done at the same time in such cases, 
before intracranial involvement occurs, the results were almost uni- 
formly favorable. That is, the combined radical mastoid and laby- 
rinth operation is a relatively safe procedure, provided, of course, 
the operator has mastered the technique, and meningeal involvement 
has not occurred. If such involvement has occurred the outlook is 
grave, either with or without an operation. 

2. The second alternative is to do the radical mastoid operation, 
exercising the greatest care to avoid trauma in the region of the pro- 
montorium, oval window, and external limb of the horizontal semicircular 
canal. But even with the greatest care reactionary inflammation is 
often excited in the labyrinth, with subsequent extension to the 
meninges. This alternative is therefore not free from danger. 

3. The third alternative is to "wait and watch" developments. 
This is, doubtless, a fascinating thing to do. I remember once watching 



FUNCTIONAL TESTS OF THE VESTIBULAR APPARATUS 895 

a cat play with a favorite pet mouse. All went well for a while, there 
were no signs of danger — to the mouse. But suddenly the feline nature 
asserted itself, and poor mousie went to its reward. As previously 
stated, there are usually no symptoms of progress in latent labyrinthitis, 
as the labyrinth is destroyed and rendered functionless, and the canals 
are so small that any acute infection therein could not materially 
influence the temperature. Any marked elevation of temperature 
present must be from involvement outside the labyrinth. There is no 
guide as to the progress of the infection toward the meninges within 
the labyrinth in such cases; hence it is only when the meninges are 
actually affected that danger is suspected, and then it is usually too 
late to avert danger, though prompt operation even then may prevent 
a fatal issue. 

In the case to be cited there was a history of total destruction of 
the labyrinth attended by a severe vertiginous attack one year pre- 
viously. There was a total loss of hearing in the affected ear, and 
chronic otorrhea with acute exacerbations of mastoiditis. These 
exacerbations had been present since the vertiginous attack one 
year ago. There has been no giddiness since the original seizure. 
The patient seeks relief from the chronic otorrhea and mastoid attacks. 
He incidentally hopes his hearing may be improved. 

Of what use may the functional test of the vestibular apparatus be 
in such a case? Again, we must be guided by past experience, which 
shows that so long as there is a vestige of hearing in the affected ear, there 
is no need for an immediate labyrinth operation. If there is a remnant 
of vestibular function left it is obvious that if an acute process lights 
up in the labyrinth and causes further destruction, there will be symp- 
toms to warn the attending otologist of the impending invasion of 
the cranial content. There will be giddiness, nausea, disturbed equi- 
librium, and spontaneous nystagmus to the healthy side. It is obvious 
that the vestibular apparatus should be tested for functional reac- 
tions, as only in cases with such reactions is it entirely safe to "wait" 
for developments. In cases in which vestibular reaction is wholly lost 
the first "signs of development" would be the symptoms of either 
diffuse suppurative meningitis or cerebellar abscess. To "wait for 
developments" in a case of latent labyrinthitis in which both the 
vestibular and cochlear functions are wholly destroyed is therefore not 
devoid of danger. 

The same principles of thought apply with equal relevancy to acute 
diffuse serous, circumscribed, and other forms of labyrinthitis. The 
presence of vestibular reaction, as shown by the tests, indicates two 
important safeguards to the patient, namely, (a) a remnant of the 
vestibular nervous apparatus is still present and acting as a barrier to 
the extension of the infection to the meninges and brain, (b) Should 
this barrier be broken down by the advance of the disease, the event 
is signalized by the usual vestibular symptom complex, namely, spon- 
taneous nystagmus to the sound side, vertigo, nausea and vomiting, 
and ataxia. Several hours, or possibly a few days, weeks, or months 



896 THE EAR 

might intervene between the onset of these symptoms and the possible 
intracranial involvement. In any event the surgeon has ample time 
to perform the labyrinth operation before the intracranial involvement 
occurs. Jansen claims, however, that meningitis may develop before 
the complete destruction of the labyrinth. We are therefore not 
always able to anticipate the onset of the meningitis or cerebellar 
abscess. The inception of meningitis is usually signalized by a reversal 
in the direction of the nystagmus. 

In view of the foregoing facts it becomes highly important to deter- 
mine the presence or absence of vestibular reaction, and to also estimate 
the degree and amount of stimulation required to elicit the reaction. 
If, in the case just cited, it could be shown by the various tests that 
vestibular reaction was present (even though the patient was totally 
deaf) the labyrinth operation should be postponed until a recurrence 
of spontaneous vestibular reaction, at which time the combined mastoid 
labyrinth operations should be seriously considered. If vestibular 
reaction could not be induced by the caloric and fistula tests, it would 
be extremely hazardous to advise waiting for developments. On 
the contrary, the patient or his friends should be plainly told the 
danger of "waiting," and of the comparatively slight danger attending 
the combined operations. He should also be told of the danger of 
having the mastoid operation done alone, and that, if the mastoid 
operation is done, the labyrinth operation should also be done at the 
same time. Probably the most conservative and rational method of 
procedure would be to proceed with the mastoid operation, and reserve 
decision as to the advisability of the labyrinth operation until the 
presence or absence of fistula is determined. If fistula is present the 
labyrinth operation, preferably Hinsberg's, should be performed. If 
fistula is absent a labyrinth operation need not be done. The absence 
of the fistula makes an extension of the infection to the meninges and 
cerebellum more improbable; whereas the presence of fistula makes 
the extension of the infection to the meninges and cerebellum more 
probable. In other words, the absence of fistula in a case with total 
destruction of the labyrinth, in which a mastoid operation is indicated, 
may be taken as a contra-indication to the labyrinth operation; whereas 
the presence of a fistula may be considered as a factor indicating the 
labyrinth operation. There can be no hard-and-fast rules in reference 
to these cases. Each must be analyzed, and the attending surgeon 
must act in accordance with his best judgment. 

Qualitative and Quantitative Estimation. — With the turning test 
both the qualitative and quantitative estimation of the vestibular 
function of the horizontal and superior semicircular canals may be 
determined, though the chief value of this test is in the qualitative 
estimation. The horizontal canals, when the head is erect, lie in the 
horizontal plane, or nearly so. The superior canals, when the head 
is erect, lie approximately in the frontal plane. To bring the latter 
into the horizontal plane, during the turning test it is necessary to 
incline the head 90 degrees either back^rd or forward. The posterior 



FUXCTIONAL TESTS OF THE VESTIBULAR APPARATUS 897 

canals cannot be simultaneously tested by the turning test. This 
test, therefore, is only applicable to the horizontal and superior canals. 

To test the horizontal canals, the patient is seated in a revolving 
chair, with his head erect, and opaque glasses over his eyes, as sug- 
gested by Hans Abels. This is done to prevent fixation of vision, as 
this might interfere with the expression of the vestibular stimulation. 
The subject is turned ten complete revolutions in the chair, and sud- 
denly stopped and the eyes observed over the rims of the opaque 
spectacles. From ten to twenty seconds should be consumed in the 
ten turnings. The quick component of the resultant induced after- 
nystagmus will constitute the direction of the nystagmus. If the 
quick component of the nystagmus is to the right, the nystagmus is 
said to be to the right. If it is to the left, it is said to be to the left. If 
the nystagmus is horizontal in direction it is called horizontal nystag- 
mus. If it is rotatory (around the pupillary axis) it is rotatory nystag- 
mus. If it is both horizontal and rotatory it is a combined horizontal 
and rotatory nystagmus. In combined nystagmus the movements 
of the eyes are always in the same direction, i. e., if the horizontal 
nystagmus is to the right, the rotatory nystagmus is to the same side. 
Only one type of nystagmus, namely, the horizontal, can be induced 
by stimulating the horizontal canal. As previously stated, it is neces- 
sary to incline the head either forward or backward 90 degrees if we 
wish to test the superior canals by the turning test (Plate XXI). 

After allowing the patient to rest a few minutes, he is turned ten 
times to the left, the turnings suddenly stopped, and the amplitude 
and duration of the nystagmus noted. If both ears are normal the 
nystagmus will continue for about forty seconds after turning in each 
direction. If, however, one labyrinth is destroyed (say the right) and 
the turnings are to the right, the after-nystagmus will be to the left, and 
will endure about twelve seconds (Plate XXV). If he is then turned to 
the left an equal number of times the nystagmus will be to the right, and 
will endure about half as long as when the turnings were to the right. 
This is due to two facts, namely, (a) the right labyrinth being totally 
destroyed, is not stimulated by the turnings in either direction; the 
nystagmus in each instance being due to a stimulation of the respective 
halves of the crista of the left horizontal canal. After the turnings to 
the right cease, the flow of the endolymph in the left horizontal canal 
is in the direction of the turning, i. e., to the right, hence it impacts 
the crista of the left canal upon its canal aspect, the side of greater 
physiological activity, and gives rise to nystagmatic movements of 
the eyes to the left, with a maximum arc of excursions, and with a 
duration of about twelve seconds. After the turnings to the left, the 
after-flow of endolymph is to the left, hence it impacts the crista of 
the left horizontal canal upon its utricular aspect, the side of lesser 
physiological activity, and gives rise to nystagmic movements of the 
eyes to the right, with a minimum arc of excursions, and with a dura- 
tion of about six seconds, or half the duration after turnings in the 
opposite direction. 
57 



898 THE EAR 

Clinical Significance of the Turning Test. — What is the significance 
of the lessened intensity and duration of the nystagmus after turning 
to the left? This: in a normal labyrinth the impulses emanating from 
the canal half or aspect of a horizontal canal are more vigorous, 
twice as enduring, as those emanating from the utricular aspect 
or half of the same crista. By turning toward the affected ear, and 
eliciting an after-nystagmus of twice the duration of that induced 
by turning toward the sound ear, the vestibular apparatus of the 
affected side is shown to be wholly unresponsive to such stimulation. 
The affected ear is destroyed as shown by this test. If the result had 
been twelve seconds after turning to the right, and nine seconds after 
turning to the left, it would have shown the right labyrinth to be still 
functionating, though somewhat crippled. The duration of the nys- 
tagmus is greatly reduced after destruction of one labyrinth. 

The quantitative test of the horizontal canals takes into account the 
number of turnings required to induce nystagmus, the amplitude of 
the excursions of the eyeballs, and the duration of the nystagmus. 
This test is used to determine the degree of imbalance existing between 
the two static labyrinths. In disease of the labyrinth the quantitative 



PLATE XXV 

Diagrammatic Illustration of Mechanism of Induced Nystagmus by Turning, the 
Right Labyrinth Having Been Totally Destroyed Six Months Previously; also Illus- 
trating the Immediate Effect of Total Destruction. 

1. The right labyrinth (R.H.C.) is represented as having been totally destroyed 
six months previously. When the turnings to the right have ceased the after-flow 
of endolymph is to the right (red arrows) in the left normal horizontal canal (L.H.C.), 
and impacts against the canal half (+) of the crista ampullaris which gives off 
impulses more than twice as strong as those given off by the utricular half of 
the crista. The path pursued by these impulses is represented by the double red 
lines to the abductors of the right eye (R) and to the adductors of the left eye (L), 
thus producing a slow conjugate movement of both eyes to the right (slow com- 
ponent). A corrective cortical impulse immediately emanates from the left cortical 
centre (C.C., left side) which causes a quick conjugate movement of both eyes to the 
left (quick component). The result is a strong horizontal nystagmus to the left, 
which continues for twelve seconds, and is indicated thus / 



<- 



2. The patient, after resting a few minutes, is turned ten times to the left and 
suddenly stopped, and the after-flow of endolymph is to the left, as shown by the 
blue arrows. The impact of the endolymph is against the utricular half of the 
crista ampullaris left horizontal canal which gives off impulses about one-half as 
strong as those from the canal half of the crista. These impulses are transmitted 
along the path indicated by the single blue line to the adductor of the right eye (R), 
and to the abductor of the left eye (L), which causes a slow conjugate movement 
of both eyes to the left (slow component). The corrective cortical impulse is imme- 
diately given off from the right cortical centre (C.C., right side), and is transmitted 
to the abductors of the right eye (R) and to the adductors of the left eye (L), thereby 
producing a quick conjugate movement of both eyes to the right (quick component). 
The resultant nystagmus is weak horizontal to the right, and it endures for about 
six seconds. It is symbolized thus, ^r. The compensation is still extra- 
labyrinthine. Vestibular compensation has not occurred. 

3. When one labyrinth is totally destroyed the discrepancy in duration, etc., 
between the nystagmus after turning to the right, and after turning to the left 
should be in the ratio of about 2 to 1. If it is twelve to nine seconds, it shows the 
apparently destroyed labyrinth as still having some function, i. e., it is not totally 
destroyed. 



PLATE XXV 




c.c. 



Acute Total Destruction of Right Labyrinth as shown by the 

Ratio of 2 to 1. 



PATHOLOGY OF LABYRINTHITIS 899 

test is essentially a test of the degree of compensation that has occurred. 
The test is made in the same manner as the qualitative test, except 
that instead of turning the patient ten times in the chair, he is turned 
twice, suddenly stopped, and the eyes observed behind the opaque 
glasses. If this fails to induce nystagmus he is turned three or four 
times, and the eyes again observed. If this fails he is turned five or 
six times, and so on, until nystagmus is induced. Note is made of 
the intensity and duration and the number of turnings required to 
induce the nystagmus. After turning in one direction the patient is 
allowed to rest a few minutes to regain static equilibrium, and he is 
then turned in the opposite direction a sufficient number of times to 
induce nystagmus. The number of turnings, intensity, direction, and 
duration are again noted and compared with the data of the opposite 
labyrinth. If the duration of the nystagmus after turning toward the 
sound ear is more than half as long as that induced after turning toward 
the affected ear, the vestibular apparatus of the affected ear is either 
normal or only partially destroyed. A labyrinth operation is contra- 
indicated, even if the hearing in that ear is totally destroyed. The 
meninges and brain are still protected by an anatomical, as well as an 
exudate barrier, from invasion. Should these barriers become destroyed, 
the destruction will be signalized by a recurrence of spontaneous nystag- 
mus, nausea, vomiting, and ataxia; warnings which usually give the 
attending otologist ample time to perform the labyrinth operation, if 
he so chooses, before the cranial content becomes involved. 

The tests are made, not so much to show whether or not the ves- 
tibular apparatus is diseased, as to show whether or not it is (a) par- 
tially, or (b) wholly destroyed. If it is only partially destroyed an 
operation is not indicated. If it is wholly destroyed a labyrinth 
operation may be and often should be done. 



PATHOLOGY OF LABYRINTHITIS 

The pathology of labyrinthitis, as given by various European writers, 
and as presented by Braun and Freisner in their work on "The Laby- 
rinth," may be summarized as follows: 

The infective microorganism is usually identical with that presented 
in the acute otitis media and mastoiditis, or in the acute exacerbation 
of the chronic otitis media and mastoiditis giving rise to the labyrinth 
inflammation. In rare cases the labyrinthitis is secondary to mumps 
and to cerebrospinal meningitis, and the infective microorganism in 
these cases is that of the primary disease. 

The Avenues of Infection. — Several avenues of invasion have been 
recognized and chief among them are the following: 

(a) Fistula of the horizontal semicircular canal (vestibular). 

(b) The oval window (vestibular and cochlear). 

(c) The round window (cochlear). 

(d) Fistula of the promontory (cochlear). 



900 THE EAR 

(e) Fistula of the cochlea at the tympanic orifice of the Eustachian 
tube (cochlear). 

if) Fistula of the facial canal (vestibular). (Grunert.) 

(g) Through the circulation, as in mumps, though in this disease 
the infection may extend through the sheath of the facial nerve. 

The most frequent site of fistula is the external limb of the horizontal 
canal. 

The next most frequent site is the oval window. The most dangerous 
site of fistula is the oval window. As the destructive process is more 
extensive in cases infected via the oval window, the histological findings 
are more abundant in this type of case; that is, more of them go to 
postmortem than those infected via the horizontal canal, though infec- 
tion by this route occurs much more frequently. 

Changes in the Oval Window. — The following changes may be 
observed through the meatus before, as well as during, the mastoid 
operation : 

(a) Destruction of a part or the whole of the annular ligament of 
the foot-plate of the stapes. 

(b) Destruction of a part or whole of the foot-plate of the stapes. 

(c) Displacement of the foot-plate of the stapes. 

(d) Destruction of the cartilaginous and bony margin of the oval 
window. 

(e) Either pus or granulations may be present in the oval window. 
Changes in the Round Window. — As the round window is hidden 

in the recess at the posterior margin of the promontory, pathological 
changes cannot be observed through the external auditory meatus 
before operation. 

Changes in the Static Labyrinth. — The pathological changes in the 
static labyrinth may range anywhere from hyperemia, serous exudate, 
purulent infiltration, round-cell infiltration, and subsequent organiza- 
tion, to destruction of the bony capsule of the labyrinth. 

The pathological process may be diffuse or circumscribed. If 
circumscribed, it may be limited to the immediate vicinity of the 
fistula, especially if the fistula is in the horizontal canal. Indeed, 
many cases of fistula in this region are observed in which the static 
labyrinth is but little disturbed in function, and the cochlea not at all 
disturbed. In the latter class of cases there may be congestion of the 
endosteum lining the bony canal, and of the membranous canal, via 
the connective-tissue bands uniting it to the endosteum. In other 
cases there is round-cell infiltration in the membranous canal, and in 
the connective-tissue supports in the immediate vicinity of the fistula. 
In others the perilymph spaces in the immediate neighborhood of the 
fistula may be filled with round-cell infiltration, which may subse- 
quently become organized into dense connective tissue, thus perma- 
nently blocking further extension of the infective process. In some cases 
the crista? of the horizontal and superior semicircular canals are either 
congested or infiltrated with round cells. 

Infection through the Oval Window. — According to Alexander, 
when a low-grade infection causes a slow perforating ulcer of the liga- 



PATHOLOGY OF LABYRINTHITIS 901 

mentiim ovale, the purulent secretion accumulates on the inner surface 
of the foot-plate of the stapes from which it gradually dissolves and 
drops into the cisterna perilymphatica vestibuli, the lymph space in 
immediate anatomical communication with the oval window. The 
cisterna perilymphatica is separated from the utricle by a heavy 
connective-tissue septa which protects the utricle from infection except 
in severe and active cases of otitis media with perforation through the 
oval window. In severe active infection this barrier does not prevent 
the extension to the utricle; indeed, the infection in such cases is usually 
diffuse and involves the entire membranous labyrinth. In the mild 
cases, the infection is often quite effectually shut off from the peri- 
lymph spaces of the ampulla, and is limited to the cisterna perilymph- 
atica vestibuli, though it may extend to the ampulla and invade the 
perilymph spaces and the semicircular canals. The infection may be 
limited to the perilymph, or it may also involve the endolymph spaces, 
as previously stated . 

Circumscribed cochlear inflammation is usually limited to the 
cisterna perilymphatica vestibuli and the first half of the basal 
whorl of the cochlea. According to Ruttin this limitation is due to 
the mild inflammation causing the perforation of the oval window 
as stated in the preceding paragraphs. The pus accumulates on the 
inner surface of the foot-plate of the stapes and gradually dissolves 
and falls through the perilymph into the cisterna perilymphatica ves- 
tibuli, and into the beginning of the scala vestibuli of the basal whorl 
of the cochlea, where it rests on Reisner's membrane. 

Ruttin has shown that when the infection extends (by rupture) from 
the cisterna perilymphatica vestibuli to the endolymph spaces, it 
usually invades the deeper ones, as the saccule, canalis reuniens, caecum 
vestibulare, or the vestibular portion of the ductus cochlearis. If 
the perforation is in the round window the infection gains entrance to 
the scala tympani of the basal whorl of the cochlea, where, if the infec- 
tion is mild, it may remain circumscribed, or if it is severe, it becomes 
diffuse and destroys the entire labyrinth. 

With the same grade of inflammation, a perforation through the 
oval window is more serious than a perforation through the round 
window. In the first instance both the vestibular and cochlear appara- 
tuses may become involved; whereas in the second only the cochlea 
may be involved. 

Circumscribed labyrinthitis is, however, generally found in the 
perilymph spaces of the horizontal semicircular canal. The connective- 
tissue barriers at the mouth of the ampulla prevent the extension 
of the infection to the vestibule. Cholesteatoma may cause a 
gradual erosion of the bony capsule of the canal and set up a peri- 
labyrinthitis, which extends to the endosteum, and from thence to 
the fibrous-tissue bands uniting the endosteum and the membranous 
canal. The endosteum and connective-tissue bands become swollen 
and infiltrated, and completely wall off the perilymph spaces beyond 
the localized area of infection. The contiguous portion of the 
membranous canal may also become swollen and infiltrated, thus 



902 THE EAR 

localizing the area of infection. Small abscesses may form in the 
membranous wall, which, thus weakened, may rupture and admit 
infection to the endolymph and membranous canal. This portion 
of the canal being swollen and infiltrated, may confine the infection 
to this area, or it may become diffuse. 

Any portion of the bony capsule may be the site of fistula, though, 
as previously stated, the external limb of the horizontal canal is the 
most frequent location. Fistula in the posterior canal is difficult to 
locate even when present, as the canal is very deeply situated. 

Mechanical Pathological Changes in Diffuse Purulent Labyrinth- 
itis. — According to Alexander, the following mechanical pathological 
changes occur in diffuse purulent labyrinthitis: 

(a) Tearing Reissner's membrane. 

(b) Destruction of neuro-epithelial cells. 

(c) Displacement of the membrana tectoria. 

Inflammatory Pathological Changes in Diffuse Purulent Labyrinth- 
itis. — (a) Exudate of pus in the perilymph and endolymph spaces. 
(6) Dilatation of the bloodvessels. 

(c) Soft tissues infiltrated with round cells and serum. 

(d) Swelling and necrosis of epithelial cells. 

(e) Suppuration may extend into the aquaductus cochleae and 
vestibuli. 

(/) The spiral ganglion, nerve fibers in the modiolus, and the internal 
auditory canal, as well as the lymph spaces may be involved. 

(g) The fibers of the eighth nerve may be degenerated. 

Bone destruction may result from the formation of granulations on 
the endosteum of the bony canals, and from the formation of an abscess 
in the subarachnoid space at the fundus of the internal auditory meatus 
over the area cribrosae (Politzer and Lange), and from an embolus of 
the internal auditory artery. The soft tissues may also be necrotic 
in these conditions. 

By the term "caries," we refer to the superficial death of tissue, as in 
ulceration; whereas by the term "necrosis," we refer to death of tissue 
en masse. Both caries and necrosis may be present in diffuse suppurative 
labyrinthitis. 

Caries results from an inflammation usually beginning in the mem- 
branous labyrinth, and if the inflammation is not intense, only carieb 
or superficial destruction occurs. If, however, the inflammation is 
intense, destruction en masse or necrosis of the tissue occurs. This 
process starts as a perilabyrinthitis (inflammation of the bony cap- 
sule), and of the periosteum lining the bony canals. The granulations 
extend into the Haversian canals of the bone and destroy the bone, 
the destroyed bone being replaced by granulation tissue. The Haver- 
sian canals become more and more spongy or porous. The spaces thus 
created become filled with granulation tissue, gelatinous intercellular 
substance, and adventitious bloodvessels. The bone becomes softened 
and decalcified. 

Necrosis of the bony capsule is due to embolus or destruction of 
the internal auditory artery, which has but slight anastomosis with 



GENERAL DIAGNOSIS 903 

the middle-ear vessels. Inasmuch as it is practically an end-artery its 
obstruction by embolus results in death of bone en masse. An abscess 
in the internal auditory canal may compress the artery and cause death 
or necrosis of a large portion of the bony capsule of the labyrinth. 
In scarlatinous otitis media the inflammatory reaction is often very 
intense, and results in necrosis of the soft tissues of the labyrinth, 
which in turn destroys arterial branches, which in turn destroys 
branches of the internal auditory artery, and is followed by necrosis 
of portions of the bony capsule. 

The necrotic bone is circumscribed and bounded by carious or 
ulcerating bone tissue which is gradually eroded and absorbed, until 
eventually the necrotic bone lies free as a sequestrum in a bed of granu- 
lation tissue (Braun and Freisner). The sequestrum usually includes 
the cochlea, as it is almost exclusively supplied by the internal auditory 
artery; whereas, only a portion of the capsule of the static labyrinth 
is supplied by it. 

If the sequestrum includes the inner wall of the tympanum (prom- 
ontorium) it may be thrown off through the middle ear and external 
meatus. If it is enveloped in healthy bone it must remain in situ until 
the enveloping healthy bone is destroyed or surgically removed. The 
sequestrum cannot be absorbed, as it contains no bloodvessels. Even 
though only a portion of the bony capsule is necrotic the whole nervous 
labyrinth is usually destroyed. 

Necrosis and exfoliation of the bony capsule of the labyrinth does 
not occur in all cases, nor, indeed, in most cases of diffuse suppurative 
labyrinthitis. In many the round-cell infiltration becomes organized 
into fibrous tissue which fills the entire labyrinth, or the labyrinth 
channels may become filled with hyperplastic or bony tissue, which 
has its origin in an irritation of the endosteum. 



GENERAL DIAGNOSIS 1 

Barany's Fixation Apparatus. — When spontaneous nystagmus exists, 
the degree of involvement of the labyrinth may be accurately estimated 
by the responsiveness of the vestibular apparatus to added external 
irritation. Before irrigating, a fixation point must be found where the 
nystagmus ceases, or is minimal. For this purpose, Barany has devised 
an instrument which is made fast to the head of the patient by a head- 
band. A metal plate with a dial, from which a metal rod extends 
at right angles, bearing a shorter pendant rod, which can be moved 
back and forth and from side to side, form the essential parts of 
this instrument. The patient fixes his eyes upon the pendant rod, 
which is moved to a point where the nystagmus is least or altogether 
disappears. When this point is determined, the affected ear is gently 

1 The section on General Diagnosis is prepared by Dr. J. R. Fletcher. The preceding portions and 
the remainder of this chapter on the labyrinth and its diseases, as it appears in this edition, is written 
by the author. 



904 THE EAR 

irrigated with cold water. If this induces an additional reaction, the 
nystagmus will reappear or increase while the patient looks at the 
fixation point. 

In severe cases of spontaneous nystagmus, this method of examina- 
tion must be very exact, as the correct diagnosis depends largely on the 
caloric test in conjunction with Barany's fixation apparatus. If, for 
instance, the history of a case is not clear, and the spontaneous nystag- 
mus is to the diseased side (extralabyrinthine), and the nystagmus is 
not reinduced or increased by this test, meningitis or cerebellar abscess 
must be present. If a positive reaction is induced, neither of these 
diseases can exist, as not a single case of either has been found up to 
this time in which the labyrinthitis has remained circumscribed. (I 
have elsewhere stated that Jansen claims meningitis has occurred before 
complete destruction of the labyrinth. 

Nystagmus in Circumscribed Labyrinthitis. — In circumscribed 
labyrinthitis the following classification must be observed: 
I. Erosion with fistula. 1 

(a) Erosion with normal irritability. 

(b) Erosion with diminished irritability. 
II. Traumatic with traumatic neurosis. 

Erosion with Fistula. — Circumscribed disease of the labyrinth 
is characterized by attacks of vertigo and nystagmus, and always by 
some impairment of hearing. Erosion with fistula is always secondary 
to disease of the tympanic cavity, which not only involves the drum 
and ossicles, but often also the bony median tympanic wall. The form 
of circumscribed labyrinthitis of greatest interest in the study of 
nystagmus is erosion with fistula. This form may remain circum- 
scribed for a long time, or it may become diffuse, or it may heal with 
the formation of connective tissue over the fistulous opening, gradually 
ossifying and closing it. 

Barany described vertigo as being of two kinds: 

1. That which occurs without external cause. 

2. That which occurs with external cause. 

1. This type comes on at any time and under all circumstances, while 
the patient sits quietly at a desk, during a meal, while walking, and 
even during sleep. Such attacks are, as a rule, quite severe and of 
long duration. They may last from one-half to several hours. The 
nystagmus is of the spontaneous rotatory type, the quick component 
of which is directed to the diseased side. There may also be a weaker 
nystagmus, the quick component of which is directed toward the sound 
side. Nystagmus occurring under these conditions is characteristic of 
circumscribed labyrinthitis. The accompanying phenomena, nausea, 
vomiting, and the sensation of movements of objects, are quite severe. 

2. The external causes of the second form of vertigo are rapid move- 
ments of the head, stooping forward, rising, inclining the head back- 

1 Irrigation is dangerous when a fistula through the lateral labyrinth wall exists. Unless the water 
is very gently passed into the ear, pus may be carried to new points, easily converting a circumscribed 
into a diffuse labyrinthitis. 



GENERAL DIAGNOSIS 905 

ward, and especially toward the shoulder of the diseased side, and 
going from a hot to a cold room, or vice versa. Usually these attacks 
are not severe and their duration is short, lasting only from a few 
seconds to a few minutes. The nystagmus is rotatory and directed 
to the diseased side; vomiting, as a rule, is absent. In the interval 
between the attacks of nystagmus the patients frequently feel per- 
fectly well, and often show no signs of nystagmus or disturbances 
of equilibrium. 

Symptoms of cochlear disease (tinnitus, marked deafness, loss of 
bone conduction, and of hearing for the tones of the upper register) 
are very often associated with either form of these attacks. Both 
forms occur in cases of erosion of the labyrinth in the course of acute 
or chronic suppurative otitis media. 

Between attacks it is usually possible to induce weak rotatory and 
horizontal nystagmus in response to both caloric tests. Occasionally 
the rotatory nystagmus, following turning while the head is inclined 
90 degrees forward, will last longer than the normal horizontal nystag- 
mus. The latter always denotes a pathological condition. 

In case of diminished irritability there is a moderate degree of rotatory 
and horizontal nystagmus (a combined spontaneous nystagmus), to 
both right and left, which is usually strongest to the diseased side, but 
sometimes to the sound side. Upon inclining the head backward, 
that is, placing the superior canal in the horizontal plane, vertigo and 
rotatory nystagmus take place in about 50 per cent, of the cases. The 
quick component of the nystagmus is directed to the diseased side; 
the duration is about fifteen seconds. After waiting ten minutes, 
the same procedure will give a like result. Compression and aspiration 
in the auditory canal and middle ear produce no nystagmus, though 
eye movements occur, but are only minimal. The response to cold 
water is quite typical, as to direction and plane of the nystagmus, but 
it is very weak. Turning ten times in the direction of the diseased 
side, head erect, produces horizontal after-nystagmus to the opposite 
side, of about thirty seconds' duration, a reduction of one-fourth the 
normal average. 

Fistula is a consequence of erosion of the labyrinthine wall. When 
the bony wall has been broken through, „the membranous canal con- 
taining the endolymph is exposed. Pressure upon it causes a dis- 
placement or flow of endolymph. Suction causes a return flow. Move- 
ments of the eyes of a nystagmatic character, produced by com- 
pression and aspiration of air in the external auditory canal and in the 
tympanic cavity, are the sign of fistula, and aid in differentiating 
labyrinthitis from cerebellar abscess. 

When the vestibular apparatus responds normally to the caloric 
test, compression and aspiration of the membranous canal through the 
fistula in the bone cause long, slow movements of the eyes, or an active 
nystagmus of some seconds' duration. When the response to the 
caloric test is partly or completely lost, very slight movements of the 
eyes may be observed during the test for fistula. It is also true that 



906 THE EAR 

exceedingly small movements of the eyes by compression and aspira- 
tion have been observed by Barany, Hennebert, and many others, in 
the absence of fistula. In such cases the response of the vestibular 
apparatus to heat and cold is normal. The latter fact excludes fistula, 
as (see above) the movements of the eyes must then be very long and 
slow. The directions of the movements differ in different cases. The 
movements which result from the compression are, however, always 
in the opposite direction to those which result from aspiration. 

II. Traumatic Circumscribed Labyrinthitis with Traumatic Neu- 
rosis. — Such cases suffer attacks of vertigo with or without the external 
causes mentioned above. In these attacks the quick component of the 
nystagmus is directed to the diseased side. The consciousness of an 
injury to the head, followed by impairment of hearing, of vertigo, 
Romberg's phenomenon, hemiparesthesia, sensitive spots, trembling of 
the eyelids, unsteady gait, especially with closed eyes, causes great appre- 
hension on the part of the patient and finally develops neurasthenia. 

These are medicolegal cases. Because of this, and for purposes of 
diagnosis, the history must be carefully studied. It is important to 
know whether the patient had vertigo, nausea and vomiting, or whether 
he was unconscious directly after the accident. If the equilibrium was 
disturbed, was it sufficient to compel him to lie down; was the hemor- 
rhage from the ear and nose ? Did vertigo come on while in bed ? Did 
movements of the head or turning in bed cause vertigo or nystagmus? 
Did the vertigo come on first upon arising from bed, or after going to 
work ? Did the vertigo tend to increase or diminish ? Answers to these 
questions determine not only the extent of injury and incapacity, and 
the kind of vertigo, but also the correctness of the statement. 

Vertigo, and in consequence incapacity for work, is the common com- 
plaint of those who receive injuries to the head, whether malingerers or 
not. In true cases, inclining the head backward causes vertigo, slight 
nausea, and weak rotatory nystagmus to the injured side. The nystag- 
mus cannot be immediately reproduced, though the patient experiences 
a strong vertigo and slight nausea. 

Syringing the injured ear between attacks with water of 78° F. or 
lower, produces typical strong nystagmus to the opposite side. The 
same procedure on the sound side gives nystagmus to the diseased side. 
Severe vertigo, nausea and vomiting, pallor, free perspiration, and 
trembling of the whole body form the usual clinical picture of traumatic 
circumscribed labyrinthitis with traumatic neurosis. The nystagmus, 
which is accompanied by vertigo, is like the spontaneous during attacks, 
but stronger. Between attacks, turning to the opposite side to the 
injury, the head erect, causes after-nystagmus quite like the normal. 
Objects seem to turn around the patient. There is no nausea, and, 
therein it is unlike spontaneous nystagmus. About three turnings, 
with the head inclined 90 degrees forward, produces rotatory nystagmus, 
with vertigo and nausea, which the patient identifies as being similar 
to the spontaneous attacks. If the patient, with or without suggestion 
from the examiner, identifies the horizontal primary, or after-nystagmus 



GENERAL DIAGNOSIS 907 

with the spontaneous attacks, he is malingering and his story is untrue. 
Those who have the real trouble make no mistakes. 

Traumatic Destruction of the Labyrinth. — An injury may cause frac- 
ture through, or sufficient hemorrhage into, the labyrinth to destroy 
it completely. The symptoms will then be the same as in acute diffused 
manifest suppurative labyrinthitis, or after the labyrinth operation. 
In short, the symptoms of labyrinth destruction are the same from 
all causes, if the patient is conscious. If the patient survives, the 
after-symptoms are those of complete labyrinth destruction of one 
side, with total deafness on the injured side. 

If the patient claims to be unable to work because of vertigo, the 
history, together with complete one-sided deafness, negative response 
to the caloric test of the injured side, and modification of the normal 
physiological nystagmus in response to turning will disprove the claim, 
as there is a readjustment of the function of equilibrium in these cases. 
Incomplete destruction is followed by the attacks of vertigo mentioned 
above. Complete destruction causes severe vertigo, nystagmus, 
nausea, and vomiting at the time of the destruction, all of which tend 
to improve from the time of onset, finally ceasing altogether. 

Nystagmus from Toxemia. — Smokers, drinkers, and those who 
suffer from auto-intoxication have spontaneous attacks of vertigo and 
nystagmus, which may or may not be accompanied by vomiting. In 
much the greater number of such patients the membrana tympani is 
intact, the vestibular apparatus responds to all tests, and perception of 
sound is normal. The nystagmus is vestibular in character, arising 
from toxic influences acting upon the centres in the fourth ventricle or 
disabling the vestibular nerve. Slight attacks of vertigo are also found 
in those who consider themselves, and who, upon examination, seem to 
be perfectly healthy. They have such attacks upon arising in the 
morning and when stooping quickly. Temporary congestion of the 
head probably causes them. 

Vertigo and Nystagmus in Neurasthenics. — Spontaneous attacks of 
vertigo of cerebral origin occur especially in neurasthenics. The 
vertigo comes on when the vision is fixed on an object for some time, 
and causes disturbances of equilibrium. The movements of the eyes 
are not of the vestibular type, though they are constant. These patients 
may fall, but in no definite direction. Apparent movement of sur- 
rounding objects is noticed by them. They also have attacks of vertigo 
of the true vestibular character when bending forward, arising in the 
morning, or upon sudden movement of the head. The vertigo, pro- 
duced by turning ten times is stronger than the spontaneous attacks. 
They become pale, tremble, perspire, and lose consciousness com- 
pletely or partly. Any or all of these symptoms may be present. 
One or two turnings, with the head inclined 90 degrees forward, produces 
vertigo and rotatory nystagmus, which the patients identify with their 
spontaneous attacks. They occur without disease of the ear, and 
stamp the neurasthenic, as do also the following symptoms, in disease 
of the ear. 



908 THE EAR 

In neurasthenics with circumscribed labyrinthitis rapid movements 
of the head produce a stronger vertigo than in neurasthenia alone. In 
about 50 per cent, of these cases such attacks can be produced upon 
the first examination by quickly inclining the head backward while the 
patient is in a sitting posture. Rotatory nystagmus to the diseased 
side and vertigo occur and cannot be reproduced by the same manipu- 
lation for ten to fifteen minutes. It is probable that the rapid movement 
of the head causes an expenditure of energy the regeneration of which 
requires this time (Barany). Vestibular disease tends to shorten the 
duration of horizontal after-nystagmus; neurasthenia tends to prolong 
it. In neurasthenics who have vestibular disease, the duration of the 
horizontal after-nystagmus 1 is normal, because the two tendencies 
counteract each other (Barany). 

Nystagmus in Acute Destruction of One Labyrinth. — The imme- 
diate symptoms of destruction of one labyrinth, from whatever cause, 
are strong rotatory and horizontal nystagmus, the quick component of 
which is directed to the sound side, occasionally to both sides. Severe 
vertigo, nausea, and vomiting, apparent movement of surrounding 
objects, sensation of turning of the body, and inability to walk, are 
often complained of. The patient must lie down, and quickly finds 
lying on the sound side to be more comfortable, because when in this 
position, in looking at surrounding objects the eyes are directed to the 
slow component which minimizes or abolishes the spontaneous nys- 
tagmus. It will be remembered that one of the characteristics of ves- 
tibular nystagmus is that it is diminished by looking toward the slow 
component and increased by looking toward the quick component. 
From the position assumed the eyes are of necessity directed toward 
the slow component, and all annoying symptoms are quickly relieved. 
The position voluntarily assumed while in bed is quite suggestive. 

The caloric and fistula tests are negative. After two or three days 
the symptoms begin to disappear, the nausea and vomiting being the 
first to subside in persons of a stable nervous system. On the third 
day there is no vertigo, while the patient keeps quiet, though the 
nystagmus persists. With quick movements of the head the nystagmus 
increases and the vertigo again comes on. When the complete operation 
on the labyrinth is done, the nystagmus and accompanying symptoms 
subside much more quickly than after diffuse suppurative labyrinthitis. 
This suggests that the stimulation of Deiters' nucleus through the 
trunk of the vestibular nerve in the latter case is so great that the 
coordination is delayed. As the conditions are the same whether 
the destruction is traumatic or toxic, the impression is conveyed 
through the nerve trunk. The cristas ampullares, being destroyed, 
the preponderance of tonus is in the opposite labyrinth, and the nys- 
tagmus is therefore directed to the sound side (Plate XXV). The 
removal of restraint allows the sound side to functionate violently, 
causing the compound nystagmus and accompanying symptoms 

1 Primary, after-, and after-after-nystagmus always refer to nystagmus produced by the turning test. 



GENERAL DIAGNOSIS 909 

to be severe. It must be remembered that a horizontal nystagmus 
frequently appears toward the diseased side when the nystagmus to 
the sound side is diminished. Bar any does not attempt to explain 
this phenomenon, as to do so would be pure speculation. 

In two or three weeks after the destruction of the labyrinth all 
symptoms disappear except a little nystagmus to the sound side, and 
occasionally slight horizontal nystagmus to the diseased side. These 
are symptoms of latent labyrinthitis which of course follows acute 
destruction. In the period of latency the sound side loses some of its 
responsiveness to both the caloric and the turning tests, probably on 
account of the changes which take place in the centres in the readjust- 
ment of the equilibrium. 

Nystagmus in Diffuse Latent Suppurative Labyrinthitis. — Weak 
rotatory nystagmus exists to both sides when the eyes are in the 
extreme lateral position, though it is somewhat stronger to the sound 
side. There is no nystagmus when the patient looks straight ahead, 
unless opaque spectacles are used, in which case very slight nystagmus 
occurs to the sound side. The caloric test of the diseased side is nega- 
tive. Cold water in the sound ear usually produces a Strong rotatory 
nystagmus to the opposite side. In some cases this reaction is weaker 
than normal. Evidently the readjustment both in the centres and the 
vestibular end-organ differs in individuals. It is probable that the 
normal end-organ takes up the function previously performed by both, 
and in one case transmits a strong impression and in another a weak 
impression to Deiters' nucleus. 

The galvanic tests for both the anode (positive pole) and the kathode 
(the negative pole) are negative, or nearly so. Aspiration and com- 
pression tests are negative. Ten turnings to the diseased side, with the 
head erect, produce horizontal after-nystagmus to the sound side of 
about thirty seconds' duration when opaque spectacles are used. Ten 
turnings to the sound side, the head erect, produces horizontal after- 
nystagmus of fifteen seconds' duration toward the diseased side when 
opaque spectacles are worn. The same turning to the diseased side 
with the head inclined 90 degrees forward produces rotatory after- 
nystagmus to the sound side of twenty seconds' duration, if the spec- 
tacles are worn (Plate XIX). Ten turnings to the sound side, with the 
head inclined forward 90 degrees, produces rotatory after-nystagmus 
of ten seconds' duration, if the spectacles are worn. (In Plate XXV 
twelve and six seconds are used.) These turning reactions are 
typical of latent uncomplicated labyrinth disease of one side, and may 
be used clinically and relied upon when the caloric test is made uncertain 
by atresia or stricture of the external auditory canal, the presence 
of a cholesteatomatous mass, or of acute suppurative otitis media. If 
the duration of the after-nystagmus to the sound side is below the 
averages given above, that to the destroyed side will not be more than 
half as long, except in those cases in which complete intralabyrinthine 
compensation has occurred, as reported by Ruttin. If the duration 
to the sound side is greater than the average, the same relation will 
persist. 



910 THE EAR 

Nystagmus by turning should be frequently produced by the surgeon 
in both normal and pathological cases if he means to become thoroughly 
acquainted with this valuable aid to diagnosis. 

Nystagmus in Meningitis. — Differential Diagnosis. — In the early 
stage the differential diagnosis between meningitis and cerebellar 
abscess is very difficult. The condition of temperature marks the 
greatest difference. The nystagmus in both cases is the same. In 
meningitis the temperature is, as a rule, relatively high, though abscess 
may also begin with this symptom. All the pressure symptoms in the 
posterior fossa may accompany circumscribed meningitis in this situa- 
tion. Hemiataxia has, however, never been observed in Politzer's clinic. 
Nystagmus of the* same vestibular character as in cerebellar abscess 
is produced by involvement of the vestibular nerve in the internal 
auditory canal. Sudden diminution of sound perception in the ear is 
more indicative of meningitis. Severe stiff-neck and hyperesthesia 
of the skin are symptoms more frequently encountered in meningitis 
than in cerebellar abscess. If the meningitis extends to the convexity, 
general convulsions, sunken abdomen, small, quick pulse, Cheyne-Stokes 
respiration, and total unconsciousness occur, and these make the diag- 
nosis simple, and, it may be added, operative interference less effective. 
In meningitis serosa there are also symptoms. The changes of tem- 
perature are slight. Sinus thrombosis, especially of the cavernous 
and lateral (sigmoid) sinuses, and middle-ear suppuration, especially 
when complicated by mastoiditis, may cause meningitis without 
involvement of the labyrinth. In these cases the symptoms are nys- 
tagmus, vertigo, vomiting, headache, and occasionally facial paralysis. 
The nystagmus is of retrolabyrinthine (namely, intracranial) origin. 

Optic neuritis, choked disk, unconsciousness, and convulsions form 
a symptom-complex which never characterizes an uncomplicated otitis 
media, though unconsciousness and convulsions may be present in very 
young children. In the latter cases, simple paracentesis, or operation 
for acute mastoiditis, will often cause the symptoms to disappear. In 
hysteria we often find otitis media with hemianesthesia, hemiparesis, 
vertigo, nausea, and disturbances of vision, but the hemiparesis and 
anesthesia are on the diseased, instead of the opposite side. 

Nystagmus of Intracranial Origin. — Intracranial nystagmus is of 
the vestibular type, with the difference that, instead of growing con- 
tinually weaker, and ceasing altogether in from twenty (rotatory 
nystagmus) to forty (horizontal nystagmus) seconds, on the average 
(physiological vestibular nystagmus), or in from a few minutes to 
several days (pathological vestibular nystagmus), it grows constantly 
stronger without the tendency to cease. The early differential diagnosis 
between vestibular and intracranial nystagmus depends largely upon 
the responsiveness of the vestibular apparatus to the caloric and 
turning tests. In cases in which the vestibular responsiveness is lost, 
a positive diagnosis can be made from the character of the spontaneous 
nystagmus (Barany, Neumann). When a labyrinth is non-responsive 
and a strong rotatory nystagmus to the same side is present, the nystag- 



GENERAL DIAGNOSIS 911 

mus must arise from some intracranial disease. When the vestibular 
end-organ is completely destroyed, it cannot produce nystagmus. The 
nystagmus which occurs to the diseased side cannot emanate from 
the sound side, because by the loss of coordination it would overbalance 
and produce a nystagmus to the side opposite to the destroyed laby- 
rinth. The presence, however, of a stronger irritation through the course 
of the vestibular nerve, or from Deiters' nucleus of the diseased side, 
will produce nystagmus to the diseased side (Plate XVII) . The accom- 
panying vertigo is very marked. If a labyrinth is destroyed, and 
there is a strong rotatory nystagmus with the quick component di- 
rected to the opposite side, it is natural to suppose that it is caused 
by the sound vestibular apparatus. This is, however, not necessarily 
true. 

If the nystagmus increases, instead of diminishing in intensity, as in 
labyrinth destruction, then it is of intracranial origin, probably due to a 
cerebellar abscess irritating the opposite half of Deiters' nucleus. 

With deafness and nystagmus of the intracranial type, and intact 
tympanic membrane, tumor along the course of the vestibular nerve is 
most probable. 

In labyrinth suppuration, in which the vestibular apparatus of the 
affected side does not respond to the physiological tests, and in which the 
nystagmus is toivard the diseased side, circumscribed meningitis of the 
posterior fossa may be present. This nystagmus is of the same character 
as that emanating from the vestibular apparatus, or that caused by 
cerebellar abscess. The differential diagnosis is made chiefly from the 
peculiarities of the pulse, temperature, etc. 

Neumann says that in cerebellar abscess the nystagmus is always of 
the rhythmic character, so thoroughly described by Barany. The dif- 
ferentiation between the vestibular nystagmus of cerebellar origin and 
that from the semicircular canals is made, on the one hand, through the 
exact examination of function of the vestibular apparatus, and on the 
other, through the course of the disease. It is not always possible to 
make a diagnosis between labyrinthitis and intracranial lesion. There 
are, of course, irregular cases. The labyrinth must first be removed 
from consideration by operation when the tests fail. 

The nystagmus induced by circumscribed labyrinthitis is directed to 
the diseased side. Should the disease progress to the destruction of the 
irritability of the vestibular apparatus, the direction of the nystagmus 
changes. It moves toward the sound side and remains there until the 
entire labyrinth is destroyed. It then gradually diminishes in intensity, 
and in a short time ceases. If the complete labyrinthine operation of 
Neumann is performed while the nystagmus is directed to the sound 
side, it remains unchanged for the first day, and then decreases notably 
for two or three days, and in a short time ceases altogether. During 
the time the nystagmus is directed toward the diseased side, the response 
to irritation is the same as in a normal ear. By irrigating with cold or 
warm water, the typical nystagmus as described by Barany appears as 
indicated above. When the direction of the nystagmus changes to the 



912 THE EAR 

sound side, the irritability of the labyrinth is usually lost, but if the 
labyrinth still responds to irrigation, the nystagmus is very weak or 
of short duration. As the disease progresses, the irritability of the 
labyrinth fails completely, and the nystagmus remains directed to the 
sound side. The nystagmus of cerebellar origin is, however, directed to 
both the diseased and the sound sides, though that directed to the 
diseased side overbalances the other. In the cases of otitic cerebellar 
abscess examined by Neumann, in which the exact examination of 
nystagmus was made, the cerebellar abscess was always a complication 
of labyrinthine suppuration. In these cases the differentiation of 
cerebellar from labyrinthine nystagmus was as follows: 

1. When the nystagmus is directed toward the diseased side, either 
a circumscribed labyrinthitis or a cerebellar abscess may be present. In 
circumscribed labyrinthine disease, irritability from irrigation is normal ; 
at the same time the symptoms of a labyrinthine fistula may exist; 
that is, compression and aspiration of air or pressure on the wall of 
the labyrinth cause nystagmatic eye movements. When irritability to 
irrigation is lost, direct pressure with a probe, or galvanization, will 
produce nystagmus. 

Under the latter circumstances, the diagnosis of cerebellar abscess 
cannot be made before the labyrinth is destroyed by operation. These 
indications, worked out by Neumann in Politzer's clinic, should justify 
adding the labyrinthine operation to the radical mastoid operation 
when in doubt. After the operation on the labyrinth, the nystagmus, 
if of vestibular origin, must change its direction to the sound side. 
Neumann has not observed a single case of cerebellar abscess associated 
with circumscribed labyrinthine suppuration. If, after the labyrinthine 
operation, rotatory nystagmus remains directed to the diseased side, 
the diagnosis of cerebellar abscess or some other disease in the posterior 
fossa of the same side is immediately made, because a destroyed laby- 
rinth never causes nystagmus to the same side. Barany and Neumann 
are of the opinion that the nystagmus toward the sound side emanates 
from the sound side. If in spite of the operative destruction of the 
labyrinth the nystagmus remains directed to the diseased side, it must 
be retrolabyrinthine in origin, through irritation of Deiters' nucleus 
or the vestibular nerve at the base of the brain. 

2. If the labyrinth does not respond to irritation (the various tests), 
and the spontaneous rotatory nystagmus is toward the affected side, 
and the pulse and temperature are characteristic, a diagnosis of cerebellar 
abscess may be made. 

3. If spontaneous nystagmus toward the sound side is present (the 
opposite middle ear being diseased) and the labyrinth on the diseased 
side is not responsive, it may be of either labyrinthine or cerebellar 
origin. In such a case it is impossible to differentiate before the laby- 
rinth operation. If the nystagmus disappears in two or three days 
after the operation, it is of vestibular origin. If, however, it does not 
cease after the operation, but increases in intensity, or changes its 
direction to the diseased side, it is of intracranial origin. 



PRACTICAL DEDUCTIONS 913 



PRACTICAL DEDUCTIONS 

1. Vestibular nystagmus is the result of a sudden loss of balance 
between the right and left vestibular apparatuses. The sudden loss 
of tonus may be due to (a) artificial stimulation, as the turning, caloric, 
fistula, and galvanic tests (induced nystagmus); or (b) it may be due 
to intralabyrinthine stimulation, or paralysis, as in the various forms 
of labyrinthine inflammation, serous and suppurative, or hemorrhage 
(spontaneous nystagmus). 

2. When both vestibular apparatuses are normal, and no unusual 
artificial stimulation is being applied, the tonus impulses which con- 
stantly influence all the voluntary muscles of the eyes, body, and 
extremities, are equal on the two sides and there is, therefore, perfect 
coordination of all the voluntary muscles. When, however, an unusual 
stimulus is applied, as in continuous turning of the body, or irrigation 
of one ear with cold water, etc., the tonus impulses in the ears or ear 
thus stimulated are increased, and incoordinate movements of the 
eyes and extremities result; that is, nystagmus, and the reaction move- 
ments of the body and extremities occur. These reactions are known as 
induced nystagmus, and induced reaction movements. When the body 
is rotated again, but in the opposite direction, or the opposite ear is 
irrigated with cold water, the nystagmus and the reaction movements 
of the body are reversed in direction, but are of about the same inten- 
sity and duration. Both vestibular apparatuses are thus shown to be 
normal (see paragraph 9). 

3. When one vestibular apparatus has been totally destroyed by 
fracture through the petrous portion of the temporal bone, and 
extralabyrinthine compensation has taken place, that is, spontaneous 
nystagmus has ceased, and the right labyrinth, the one recently 
destroyed, is irrigated with cold water, neither nystagmus nor the 
reaction movements of the body will occur, as the labyrinth is dead. 
If the normal left ear is irrigated, nystagmus and the reaction move- 
ments will be aroused. Such a patient having passed through the acute 
diffuse manifest stage of labyrinthitis without involvement of the 
meninges and brain, there is no indication for an immediate labyrinth 
operation. Such cases do not always, or even usually, pass through this 
stage so fortunately. Indeed, many of them subsequently develop 
meningitis or cerebellar abscess, and die. If seen at the time of 
total destruction of the labyrinth, as shown by total loss of hearing 
and vestibular response to the caloric test, etc., it would have been 
perfectly proper to have seriously considered the advisability of per- 
forming a labyrinth operation at once. Authorities differ on this 
point, though an immediate operation seems to afford the better chance 
for the life of the patient. Some of them will die even though an opera- 
tion is done. Probably more will die if it is not done, especially if it is 
postponed long after latency is established, as cerebellar abscess often 
develops in the course of diffuse latent suppurative labyrinthitis. The 

58 



914 THE EAR 

case having, however, safely passed through the acute destruction, the 
question of operation must be viewed differently. If the patient still 
suffers from mastoiditis and requires a mastoid operation for its cure, 
the labyrinth should also be operated at the same time, especially if 
during the mastoid operation a fistula of the labyrinth is found, 
and more especially if it is located in the oval window. Experience 
has shown that if only the mastoid operation is performed in such 
cases, a reactionary inflammation may be lighted up and extend to the 
meninges or cerebellum and result fatally. Furthermore, the infection 
may extend to the meninges or cerebellum at any subsequent time, 
even without a mastoid operation. As the hearing is already destroyed 
in the affected ear, and cannot be rendered worse by a labyrinth opera- 
tion, and the operation is not, of itself, attended by a high mortality 
rate (provided the meninges or cerebellum are not involved), the 
period of latency affords a peculiarly favorable time to perform the 
labyrinth operation. 

If, in the example referred to in the preceding paragraph, the right 
labyrinth has been only partially destroyed (one month previously) 
and extralabyrinthine compensation had occurred, and the right ear 
had been irrigated with cold water, a weak nystagmus toward the 
normal side would have been induced, but of shorter duration than 
normal; whereas cold irrigation in the sound ear would have induced 
nystagmus of normal intensity and duration to the diseased side. These 
results indicate a partial destruction of the right or affected labyrinth. 
When partial function is shown, there is no probability of the infection 
immediately invading the meninges and brain, at least, not without 
fulminating vestibular symptoms; hence no indications are present 
for an operation on the affected labyrinth. 

4. Serous labyrinthitis is not usually a dangerous disease, though 
it may become so if it is converted into the diffuse suppurative type. 
When thus converted it should be treated in all respects as an acute 
diffuse suppurative manifest labyrinthitis. 

5. Circumscribed labyrinthitis is not, of itself, a dangerous disease, 
but when it becomes converted into an acute diffuse manifest suppura- 
tive labyrinthitis it is a serious condition which must be treated as 
such. 

6. The presence of even a vestige of hearing in the affected ear is 
a contra-indication to the labyrinth operation, not because there is no 
danger of the infectious process invading the meninges and cerebellum, 
because there is this danger; but because, if it should extend to the 
cranium, warning, in the form of complete deafness in the affected 



PLATE XXVI 

Right labyrinth totally destroyed several years ago, showing complete vestibular 
compensation after the lapse of several years. The two halves of the crista of the 
healthy labyrinth become equal in tonus, whereas normally their tonus is 2 to 1, 
the canal half of the crista having a tonus of 2 and the utricular half a tonus of 1. 
Doubtless the stronger half atrophies and the weaker half hypertrophies until the 
two become equal. 



PLATE XXVI 




Complete Vestibular Compensation Several Years after the 
Labyrinth was Destroyed. 



PRACTICAL DEDUCTIONS 915 

ear, and of nystagmus and the reaction movements of the body and 
extremities, will occur at the moment of the destruction. When these 
danger signals become manifest the labyrinth operation should be 
performed without delay, as the delay of a few days might allow 
meningitis or other intracranial involvement to develop, and thus 
render the prognosis quite grave; whereas prompt operative measures 
would have rendered the prognosis very good. Jansen and others 
have reported cases in which meningitis occurred before complete 
destruction of the labyrinth, though this is exceptional. 

7. The presence of a vestige of vestibular reaction to the caloric 
or fistula test is also a contra-indication to the labyrinth operation, at 
least to an immediate operation. The presence of vestibular reaction 
to the caloric and compression stimulation shows a mechanical ana- 
tomical barrier between the labyrinth and the cranial content. Should 
these barriers be suddenly destroyed, the spontaneous nystagmus and 
the reaction movements will again become manifest, and thus warn 
the attending otologist of the progress of the infection toward the 
meninges and cerebellum. When, subsequently, the tests show the 
total destruction of hearing and vestibular reaction, an immediate 
labyrinth operation may be advised. 

8. In pathological processes of the labyrinth the vestibular tests 
are performed to estimate (a) the presence or absence of vestibular 
reaction, (b) the degree of stimulation required to produce vestibular 
reaction, and (c) the intensity and duration of the vestibular reaction. 
By ascertaining these facts and considering them in association with 
all the other clinical phenomena, the type of labyrinth disease may 
be determined, the prognosis formulated, and the indications for 
treatment outlined. 

9. The reactions induced by the vestibular- tests in disease of the 
labyrinth are sometimes greatly modified by the amount and type of 
compensation which has occurred. For example, in three or four 
weeks after an acute sudden destructive process in the labyrinth, 
compensation apparently occurs; that is, the spontaneous nystagmus 
and reaction movements so far subside that the ordinary methods of 
observation do not detect them. Slight stimulation would, however, 
make them manifest again. Two years later it might require a stronger 
stimulation to make them manifest. Eight or ten years later compensa- 
tion may be complete; so complete, indeed, that the two halves of 
each crista of the normal labyrinth may have equal tonus, as evi- 
denced by inducing nystagmus of nearly equal intensity and duration 
by the turning test to the right, and then to the left (Plate XXVI). 
Such reactions to the turning tests would ordinarily be interpreted as 
showing both labyrinths as normally functionating, whereas, as a matter 
of fact, in the instance cited, one labyrinth is totally destroyed and 
out of commission, and complete intralabyrinthine compensation has 
occurred. Hence, as I have already repeatedly said, the tests of the 
vestibular portion of the two labyrinths are of clinical value insofar 
as they show the equality or the inequality of tonus impulses emana- 



916 THE EAR 

ting from them, and more especially in circumscribed, serous, and 
acute diffuse manifest suppurative labyrinthitis, and in the earlier 
months or years of diffuse latent suppurative labyrinthitis. The dura- 
tion of the reactions are greatly shortened but are of about equal 
duration. 

10. The functional tests of the vestibular apparatus are also of 
value in differentiating labyrinthitis from cerebellar disease, meningitis, 
etc. The nystagmus in cerebellar disease may be greatly intensified 
by the cold caloric test; or, if it is but slightly manifest before the 
caloric test, so slight, indeed, as to escape ordinary observation, it will 
produce a nystagmus of great intensity and duration. This is known 
as Neumann's enduring nystagmus reaction. 

11. When meningitis occurs in the course of an acute diffuse mani- 
fest suppurative labyrinthitis, the nystagmus may change its direction 
to the normal side, whereas, before the meningitis occurred, it was to 
the diseased side. 

12. Spontaneous vestibular nystagmus rapidly declines in intensity, 
and within a few hours, days, or weeks disappears. 

13. Cerebellar nystagmus tends to continue indefinitely and to 
increase in intensity. 

14. In spontaneous vestibular reaction movements, the patient 
tends to fall toward the slow component of the nystagmus, and the 
direction of falling is influenced by the position of the head, whereas, 
in cerebellar nystagmus, the slow component of the nystagmus and 
position of the head have no influence on the direction of the falling. 

Other facts might be tabulated under the caption of this section, 
but the above summary will suffice to place in concrete form the more 
important practical deductions in reference to nystagmus, and the 
vestibular tests in relation to labyrinth disease. 



CHAPTER L 



LABYRINTHITIS: ILLUSTRATIVE CASES 

So much has been written about the theoretical aspect of the laby- 
rinth, and disease thereof, that there is danger of the real and imme- 
diate demands upon the clinical otologist being submerged under a 
mass of literary opinions, which may well leave him in a nebulous 
haze of confused ideas. It will be my endeavor in this chapter to 
formulate some of the more simple and practical problems, in relation 
to disease of the labyrinth, with which the clinical otologist is more 
or less frequently confronted. The more theoretical and abstract 
propositions, which are of so much interest, and the solution of which 
will ultimately benefit the profession and suffering humanity, have 
been discussed in the preceding pages, hence our attention at this 
time will be confined to the consideration of the well-recognized clinical 
manifestations of labyrinth disease, and more especially as they are 
observed in practice. We will assume that not all otologists are fully 
prepared to give these cases the attention they need. This is due to 
confusion as to the relative importance of the clinical phenomena, 
and the theoretical problems which are usually considered in the 
discussion of these cases. While the theoretical problems are of impor- 
tance in the analysis of these cases, the clinical aspect must ever be 
given the greater attention if we wish to be of the greatest service 
to our patients. 

The consideration of a few typical cases selected from my practice 
may help to "get a line" on this disease, to the extent that we may 
at least give those thus afflicted intelligent advice, rather than evasive 
or unintelligible information, such as was given by an otologist who 
said he operated upon a labyrinth to improve the hearing. 

The type of labyrinth disease more often and easily recognized is 
characterized by the total destruction of hearing in one ear, which at 
the time of destruction was either a diffuse manifest or a diffuse serous 
labyrinthitis, and in its later manifestation is known either as diffuse 
latent suppurative labyrinthitis or as a dead auditory labyrinth from 
profound serous disease, though total destruction of the labyrinth is 
probably rare in serous labyrinthitis. In simple words, this is a case 
in which weeks, months, or years previously there was a diffuse mani- 
fest suppurative labyrinthitis or a diffuse serous labyrinthitis of the 
fifth degree (see Serous Labyrinthitis) which caused total destruction 
of the organ of hearing (the organ of Corti of the cochlea), and in addi- 
tion to this, the static labyrinth (semicircular canals, ampullae, and 

(917) 



918 THE EAR 

crista ampullares) was wholly or nearly wholly destroyed. I have 
seen several cases in which there was total destruction of the cochlea, 
but in which there remained some vestibular function, as shown by 
the fistula and caloric tests. This is explained upon the theory that 
the vestibular portion of the eighth cranial nerve is more resistant 
than the cochlear portion. It is probable, therefore, that in so-called 
diffuse manifest suppurative labyrinthitis total destruction does not 
always occur in the vestibular end-organs, i. e., the crista? ampullares. 
Some authors classify these cases as severe serous labyrinthitis, upon 
the theory that acute manifest suppurative labyrinthitis is always 
attended by complete destruction of both the cochlear and vestibular 
apparatuses. Further observation and postmortem findings will be 
required to establish the truth respecting the matter. It is perfectly 
conceivable, however, that in acute diffuse manifest suppurative 
labyrinthitis, the crista? ampullares may be only partially destroyed, 
and that in diffuse serous labyrinthitis the cochlea may be 
totally destroyed and the crista? only partially destroyed. We are 
advised by eminent authorities, however, that those cases in which 
there was total and permanent deafness and abolition of vestibular 
reaction, were of the acute diffuse manifest suppurative type of laby- 
rinthitis, and that those cases in which total deafness and partial loss 
of vestibular reaction were of the diffuse serous type of labyrinthitis. 
The solution of this phase of the subject assumes considerable impor- 
tance, as serous labyrinthitis, even when of the severest degree, is not 
as liable to be attended or followed by intracranial disease as is 
acute diffuse manifest suppurative labyrinthitis, especially if fistula is 
present. If total destruction of the cochlear and static labyrinth 
should occur in serous labyrinthitis, there would be no actual justi- 
fication for the labyrinth operation, as this process is not liable to 
involve either the brain or meninges. If an operation is performed 
it is based upon the assumption that the total destruction of the static 
and auditory labyrinths points almost incontrovertibly to a suppura- 
tive labyrinthitis. If, on the contrary, it can be demonstrated that 
the total destruction of the cochlear and vestibular apparatus is due 
to acute diffuse manifest suppurative labyrinthitis the indications 
for the labyrinth operation are much stronger and may be imperative. 
For example, if upon inspecting the ear through a perforation in the 
membrana tympani, pus is observed oozing through a perforation 
in the promontorium, the case is undoubtedly of the suppurative 
type. 

It appears, therefore, that until more discriminating methods of 
diagnosis are adopted, that we must either maintain an expectant 
watchful attitude toward the doubtful cases, or regard all such cases 
as suppurative and a grave menace to life. The latter attitude carries 
with it the assumption that these doubtful cases should be given the 
benefit of the doubt, and treated or operated as diffuse manifest sup- 
purative labyrinthitis. This assumption carries with it another one, 
namely, that more lives are saved by the operation than would be 



LABYRINTHITIS; ILLUSTRATIVE CASES 919 

by "waiting for developments," or to express it differently, more 
cases will die if such cases are "watched" for intracranial involvement 
than if operated at the time of the total destruction. Most authorities 
prefer to keep these cases under the closest observation, and if no pro- 
gression is indicated, i. e., if the temperature does not remain elevated, 
and if headache, etc., do not become more pronounced, to avoid 
a labyrinth operation. These cases seek advice as to their defective 
hearing, chronic otorrhea, etc. The problems are, What can be done 
to either relieve or cure the remaining disease? Is his health or life 
endangered ? If so, what can be done to improve his health, or prevent 
death? These are the problems confronting the otologist. He is not 
so much concerned with the refinements of the pathology or the theories 
explaining the various reactions to the tests of the labyrinth as he is 
with the immediate needs of his patient. 

I have selected typical cases from my practice to illustrate some of 
the clinical aspects of labyrinthitis, and hope to present them as indi- 
vidual problems to each reader. As each case is presented, I will 
endeavor to formulate the mental problems presented in its analysis. 
By this method of presentation I hope to put the consideration of 
labyrinth disease upon a simple clinical basis suited to the embryo 
labyrinthologist, rather than upon a complex and often confusing 
laboratory basis, which is only available to the more advanced student. 

Case I. — Mr. F., aged forty-five years. Consulted me March 6, 
1912, complaining of deafness in the right ear, from which there had 
been a chronic discharge for ten years. Ten years ago he had an 
attack of acute tonsillitis which was followed by a severe inflammation 
of both ears, followed by a discharge of purulent matter. During the 
acute attack he become nauseated, and vomited when he attempted 
to move about. He was confined to his bed for several days. He was 
giddy when upon his feet, and had to be supported to the toilet room. 
The room seemed to whirl about him, though in what direction he 
does not remember. Was totally deaf in the right ear at that time, 
and has remained so since then. Has had numerous giddy attacks 
since the right ear was destroyed, though he has never fallen to the 
ground during one of them. 

At the time he consulted me he was complaining of giddiness, deaf- 
ness in the right ear, and a thin seropurulent discharge from the same 
ear. Had recently passed through an attack of acute coryza which 
he thought brought on the giddiness and increased the discharge. 

The first problem presented in this case was, Is the patient totally 
deaf in the right ear, or is he only partially so? As the solution of 
this problem would reflect light upon the general character of the 
disease in the right ear, it was important to determine at once whether 
or not the patient was totally deaf in the affected ear. Total deafness 
rarely or never occurs in adhesive processes in the middle ear or in 
otosclerosis. It only occurs in diffuse suppurative labyrinthitis, diffuse 
serous labyrinthitis, and in fractures through the petrous portion 
of the temporal bone, etc. Hence, if this case was totally deaf in the 



920 THE EAR 

affected ear, it would, in view of the previous history, point to a com- 
plete destruction of the auditory labyrinth during the primary disease, 
ten years previously. At that time he obviously suffered from either 
diffuse serous labyrinthitis in the fifth or extreme degree, or from 
acute diffuse manifest suppurative labyrinthitis, and is at present 
affected with a dead, auditory labyrinth, with bony fistula, and still 
has some function of the static labyrinth. Had he been affected by 
diffuse manifest suppurative labyrinthitis ten years ago, both the 
auditory and static labyrinths would, in all probability, have been 
totally destroyed. As the static labyrinth still has some function 
left, as shown by the attacks of giddiness and the slight response to the 
fistula compression test, the original disease may have been serous 
in character, though it is possible that he may have had manifest sup- 
purative labyrinthitis without total destruction of the static labyrinth. 
Partial destruction is, however, rare in this type of disease. 

To determine the question of partial or total deafness was the first 
problem to be solved. How was this done? To the otologist, trained 
in labyrinth work, this question may appear puerile. I know some very 
reputable otologists, however, who in their present state of knowledge 
could not answer it. Their methods of observation pursued are often 
misleading. Only recently a physician of deservedly high reputation, 
but who had not fully grasped the labyrinth problem, brought a case 
to my office for consultation. When I offered to test the hearing he 
exclaimed, "There is no use testing the hearing, as I did it yesterday, 
and found he heard the watch on contact with the affected ear." 
I replied that I only wished to determine the "degree of hearing," 
and proceeded to use Barany's noise apparatus to make the test for 
total deafness, and found the patient to be totally deaf in the affected 
ear. 

The test for total deafness (destruction of the auditory labyrinth) 
is made with Barany's noise apparatus which consists of a small 
alarm clock (minus the time element) provided with an ear-piece 
fitting the external auditory meatus. This was tightly inserted into 
the external auditory meatus of the sound ear of the patient, and 
pressure upon a button set off the alarm or noise apparatus. This 
completely shut off the hearing in the sound ear, but did not affect 
it in the diseased ear. I then addressed the diseased ear with increasing 
loudness up to the shouting voice, and the patient did not hear a 
sound; that is, he was totally deaf on the affected side. This showed 
total destruction of the auditory labyrinth of the affected ear. The 
static labyrinth still retained some function, as was shown by the 
fistula test and by the history of the attacks of giddiness. The cold 
caloric test elicited nystagmus to the opposite side, though it was very 
weak and of short duration. The turning test to the right, or toward 
the affected ear, induced a nystagmus to the left of eight seconds' 
duration. Turning to the left induced a nystagmus to the right of 
eight seconds' duration. The ratio was 1 to 1, showing complete ves- 
tibular compensation. The turning test therefore corroborated the 



LABYRINTHITIS; ILLUSTRATIVE CASES 921 

caloric test. Having settled the first problem, namely, that the 
cochlear labyrinth was totally destroyed, the next problem was, Is the 
static labyrinth totally or only partially destroyed? The history of 
recurrent attacks of giddiness and the results of the fistula test showed 
that the static labyrinth (cristas ampullares) still retained some 
function. The original disease, therefore, was probably serous 
labyrinthitis rather than diffuse manifest suppurative labyrinthitis, as 
in diffuse manifest suppurative labyrinthitis both the cochlea and 
static labyrinths (the vestibular nerve endings) are almost always 
totally destroyed. It should be repeated, however, that we have no 
diagnostic means at our command whereby we can determine with 
absolute certainty whether the disease is serous or suppurative in 
character. 

A mastoid operation, done alone, might excite a reactionary inflam- 
matory process in the labyrinth, and cause its extension to the meninges 
or brain. If the mastoid operation is imperative, safety would be more 
assured by removing the labyrinth at the same time. If this is not 
done the closest observation of the case should be maintained and the 
earliest fulminating symptoms, as severe persistent headache, giddi- 
ness, nausea and vomiting, should be regarded as imperative indications 
for the labyrinth operation. I cannot refrain from again repeating 
what I have so often said before, that waiting for these fulminating 
symptoms is somewhat like waiting to see the mouse go into the cat's 
stomach before attempting to rescue it. In the presence of such mani- 
festations an immediate labyrinth and mastoid operation is indicated, 
especially if a fistula is present. The hearing being already wholly 
destroyed, does not constitute a contra-indication to the operation. 
A contra-indication to the labyrinth operation is the likelihood of 
exciting meningitis by it. This is not likely, however, as with the 
Jansen-Neumann operation the meninges at the site of probable 
infection would be freely exposed (see Surgery of Labyrinth). The 
danger usually mentioned as attending this operation is the possibility 
of injuring the dura. This is not probable if the dura is elevated before 
removing the petrous bone containing the semicircular canals. In 
this case the whole of the diseased labyrinth should be removed as 
it is suppurating, a wide, open wound established, and the meninges 
widely uncovered and drained. Thus operated the patient should be 
permanently cured of the offensive discharge and giddiness, and be 
forever relieved of the menace of cerebellar abscess and meningitis. 
Case I, as referred to, was operated by me in May, 1912, by the 
Jansen-Neumann method, immediately following the radical mastoid 
operation. His recovery was uneventful and the discharge has ceased, 
and giddiness is no longer a factor in the case. 

Case II. — Mrs. B., aged fifty years. Twelve years ago she had a 
discharge from the same or opposite ear, she could not remember 
which. Six weeks ago she had acute tonsillitis, followed by an earache 
on the left side. Paracentesis of the drum-head was performed by a 
competent otologist, and this was followed by a purulent discharge. 



922 THE EAR 

Four days before I was called she had an attack of vertigo, giddiness, 
nausea and vomiting, and nystagmus to the right or healthy side. She 
was prostrated, and movements in bed aggravated the symptoms. 
Her condition at the time of the consultation was as follows: (a) 
Spontaneous rotatory nystagmus to the right or healthy side; (6) total 
deafness in the left ear, as shown by Barany's noise apparatus in the 
sound ear; (c) fistula symptom absent; (d) the knee reflex on the left 
side was slightly exaggerated; (e) Babinsky was negative; (/) the pupils 
were unequally contracted; (g) the temperature ranged from 101° to 
102° F.; and (h) she complained of continuous headache. 

The patient was removed to a local hospital, where I performed a 
combined radical mastoid, and a Jansen-Neumann labyrinth opera- 
tion. The facial nerve was not injured. The patient was in excellent 
condition at the end of the operation, but died one week later of 
meningitis. 

The first problem in this case was to make the diagnosis. This 
was not an easy one, though it was fairly obvious that it was diffuse 
manifest suppurative labyrinthitis, complicated by, or immediately 
threatened with meningitis. The caloric and fistula tests, applied to 
the left ear, were negative. That is, no nystagmatic reactions were 
induced by them. This was very significant. Inasmuch as the laby- 
rinth was destroyed, as shown by (a) the complete deafness upon the 
affected side, and (b) the caloric test, did not produce vestibular response 
(because the static labyrinth was destroyed), I made a diagnosis of 
diffuse manifest suppurative labyrinthitis, complicated by meningitis. 
I differentiated it from diffuse serous labyrinthitis, because in the 
latter disease neither the caloric nor fistula test induced vestibular 
reaction. Furthermore, meningitis was suggested by the unequally 
contracted pupils, slightly exaggerated knee-jerk, and severe headache, 
etc. The atrium of the intracranial invasion was probably through 
the sheath of the eighth nerve, via the internal auditory canal or 
through some other point on the posterior wall of the pyramid. 

The second problem was the indications for treatment. Obviously 
local and systemic remedies were out of the question. A general law 
relating to acute infection is that free drainage of an infected cavity 
will usually result in a cure of the infectious process. In this case the 
infection was in the tympanic cavity, the mastoid cells, labyrinth, and 
the cranial cavity around the opening of the internal auditory canal 
on the posterior wall of the petrous portion of the temporal bone. 
To establish drainage of these areas it was necessary to do a radical 
mastoid operation, and a labyrinth operation, which would expose 
the meninges as deep as the internal opening of the internal auditory 
canal. Meningitis is as easily cured as peritonitis, provided equally 
good drainage can be established. This is possible at the very inception 
of meningitis jji this region, if the Jansen-Neumann operation is per- 
formed, though if the operation is delayed the deeper arachnoid spaces 
become filled with coagulated serum and pus, which will not drain 
away, no matter how extensive the opening may be made. Hence, if 



LABYRINTHITIS; ILLUSTRATIVE CASES 923 

the operation is performed early enough a cure may sometimes be 
expected, as the reported cases show. If, however, the meningeal 
inflammation has spread much beyond the area immediately sur- 
rounding the atrium of infection a cure should not be expected, as 
drainage cannot be full}' established. In this case I was in some doubt 
as to the extension of the meningitis, though the pupils were un- 
equal, the knee-jerk slightly exaggerated, and headache severe. There 
was, however, a possibility of opening and draining in time to avert a 
fatal issue. I therefore decided to do a combined radical mastoid and 
Jansen-Xeumann labyrinth operation at once. The subsequent devel- 
opment of the case, and the death of the patient, justified my earlier 
fears as to the extension of the meningitis. This case illustrates the 
extreme danger of delaying the labyrinth operation beyond the time 
of the inception of meningitis. Indeed, it would have been safer in 
this case to have operated as soon as total destruction of the labyrinth 
occurred, as shown by the total loss of hearing, rather than to have 
waited for the inception of the meningitis. The mortality rate in 
such cases could be greatly lowered if this were always done. In 
diffuse manifest suppurative labyrinthitis, with total loss of hearing 
and the absence of caloric and fistula reactions, a combined mastoid 
and labyrinth operation would probably lower the mortality rate. 
Spinal puncture would have given positive information as to the 
presence of suppurative meningitis, but this was not done because a 
suitable hollow needle was not available, as the patient was in a 
village far removed from the base of supply. 

Total destruction usually occurs at the time of the "attack," con- 
sisting of nystagmus to the unaffected side, giddiness, nausea and 
vomiting, and disturbance of equilibrium. Little or no warning of 
the impending disaster is given. The case, just previous to the attack, 
was either one of chronic otorrhea or mastoiditis, or acute mastoiditis, 
with or without circumscribed labyrinthitis. Immediately after the 
"attack" occurred the hearing should have been tested with the noise 
apparatus, and if total deafness was shown, and especially if there was 
no reaction to either the caloric or fistula test, the labyrinth operation 
should have been considered at once. Delay only invited danger. 
The operation could have done no harm, as the hearing was already 
destroyed, and it might have saved the life of the patient. The patient 
would almost certainly have died without the operation, and might 
have been saved by an early labyrinth operation. 

Case III. — Mr. Y., aged thirty-four years, complained of recurring 
attacks of dizziness upon stooping, quick movements of the head, and 
other unaccustomed movements. He occasionally had attacks of 
even greater severity independent of the stooping or jarring movement 
of the head and body. He was suffering from one of the attacks when 
I first saw him. The attacks were characterized by vertigo, nausea, 
and vomiting, staggering gait, and spontaneous nystagmus. The 
nystagmus was directed to either side, especially when the eyes were 
turned in either direction, though it was stronger toward the affected 



924 THE EAR 

side. When looking to the right the nystagmus was to the right, and 
when looking to the left the nystagmus was to the left, though it was 
stronger when looking to the right. The nystagmus was rotatory in 
type. There had been discharge from the right ear since childhood. 
The vertiginous attacks had occurred at intervals for four or five 
years. 

The rotation test showed both labyrinths to be functionating nor- 
mally. An examination of the ears showed the left to be normal. In 
the right ear there was a total loss of the membrana tympani, malleus, 
and incus. A thin, purulent secretion filled the fundus meati. There 
was no mastoid tenderness, though the skiagraph, subsequently made, 
showed extreme cloudiness of the mastoid cells, and of the antrum. 
The hearing was impaired in the right ear, the whispered voice being 
heard five feet. Weber lateralized to the right; Rinne in the right ear 
was negative; in the left, positive. Tinnitus was present but not 
marked. Fistula symptom was present. The caloric reaction was 
present about equally in both ears. 

The first problem in this case was the diagnosis. This was not 
difficult in view of the history of recurring attacks of giddiness and 
nausea upon stooping, and sudden or jarring movements of the head 
or body. Of much greater significance, however, were the attacks 
of giddiness, spontaneous nystagmus, etc., when resting quietly in 
a chair, and in bed. In addition to these phenomena, the positive 
fistula reaction left no room for doubt as to the nature of the disease. 
A diagnosis of circumscribed labyrinthitis with fistula was made. 

The second problem was the treatment. Should it be expectant, 
local, or surgical? Inasmuch as the disease was localized and non- 
progressive, and the hearing intact, operation on the labyrinth was 
not considered, as the presence of hearing, even in the slightest degree, 
is a positive contra-indication to surgery of the labyrinth. The mastoid 
operation remained to be considered. It was obviously indicated 
insofar as the mastoid was concerned. The influence of the mastoid 
operation upon the future course of the labyrinth disease was taken 
into account. Experience has shown that with the proper precautions 
the mastoid operation may be performed without arousing the circum- 
scribed labyrinth disease into greater activity, or causing it to spread 
and become diffuse. Without these precautions the mastoid operation 
might be very dangerous. Having demonstrated the nature of the 
disease, and that a bony fistula was present, I was fully aware of the 
dangers of the situation, and proceeded with the mastoid operation, 
with full confidence as to the favorable outcome of the same. 

The precautions observed were (a) the avoidance of meddlesome 
probing of the labyrinth fistula, and (b) the avoidance of currettage of 
the inner wall of the tympanic cavity, especially as granulations were 
present. Traumatism of the inner wall of the bony wound was scru- 
pulously avoided. As to the labyrinth, nothing was done. The radical 
mastoid operation was performed and a bony fistula, the size of a 
large grain of wheat, was found leading to the horizontal canal. Granu- 



LABYRINTHITIS: ILLUSTRATIVE CASES 925 

lations filled the bony fistula. Two years have elapsed since the opera- 
tion and the vertiginous attacks have been less frequent and much 
less severe in degree. The probabilities are that the labyrinth disease 
will remain circumscribed and the toxic and congestive irritations will 
cease, and an ultimate recovery from the "vertiginous attacks" take 
place. 

Case IV. — Female, aged twenty-three years. She was complaining 
of sudden and severe attacks of vertigo, nausea, and vomiting, pros- 
tration, and of falling to the right. Moving about and attempting to 
sit up in bed to take food increased the vertiginous attacks. She was 
very deaf in the right ear. At times the surrounding objects seemed 
to whirl about her. 

Upon testing the right ear, with Barany's noise apparatus in the 
normal left ear, a remnant of hearing for the shouted voice was shown. 
Fistula symptom was present, but required two or three violent com- 
pressions of the air-bag to produce it. The caloric reaction in the 
affected ear was present but weakened. Spontaneous nystagmus to 
the sound ear (sign of destruction disharmony) was present. 

There was a history of several vertiginous attacks during the past 
six years, though they were much less severe than the present one. 
Her hearing previous to the recent severe attack was good, though 
somewhat impaired. She has had otorrhea with occasional mastoid pain 
and tenderness for eleven years. Eleven years ago she had an attack 
of tonsillitis, which was followed by acute otitis media, eventuating 
in chronic otorrhea, which has been accompanied by the aforesaid ver- 
tiginous attacks at varying periods of time. 

The first problem in this case was the diagnosis. In view of the fact 
that deafness, while profound, was not total, and that there was a his- 
tory of recurrent vertiginous attacks of moderate degree of severity 
during the preceding eleven years, that fistula symptom was present, 
that no previous operation had been performed upon the left ear, and 
that the present attack was severe and attended by almost total 
deafness, I made a tentative diagnosis of diffuse serous labyrinthitis. 
Had diffuse suppurative labyrinthitis been present the loss of hearing 
would have been both sudden and complete. The presence of some 
hearing and of static function in the affected ear ruled diffuse manifest 
suppurative labyrinthitis out of consideration. The only other type 
of labyrinthitis attended by almost total deafness of sudden develop- 
ment, is the serous variety. Hence a tentative diagnosis of diffuse 
serous labyrinthitis was made. If the disease subsequently proved 
to be of the serous type, the hearing would gradually be restored, an 
occurrence which could never happen in diffuse manifest suppurative 
labyrinthitis. 

Within five days the vertiginous symptoms had almost disappeared 
and within two weeks the hearing was restored to such an extent that 
the whispered voice would be heard at three feet. There remained no 
longer any doubt as to the serous nature of the labyrinthitis. Operation 
in this case was not considered. 



CHAPTER LI 

SURGICAL DISEASE OF THE LABYRINTH 
GENERAL REMARKS ON LABYRINTHITIS 

Suppurative inflammation of the labyrinth is one of the most 
serious menaces to life, hence an accurate description of its character- 
istic phenomena should be delineated for the enlightenment of those 
who practise medicine and surgery. Unfortunately observations have 
thus far been too few to enable one to give an absolutely correct and 
dependable clinical picture of the infectious processes as they occur 
in the labyrinth. Indeed, their manifestations are so various in differ- 
ent individuals, and in the same individual at different times, that the 
task becomes all the more difficult and complicated. Then, too, the 
prognostic significance and the therapeutic indications attending each 
of the manifestations of labyrinthitis render it a most difficult and 
intricate problem. The advancement of knowledge along these lines, 
has, however, been sufficiently definite to warrant a fairly accurate 
clinical definition of the various labyrinthine inflammatory diseases. 
There is, however, still so much unknown as to the pathology, and 
even the physiology of the labyrinth, that we do not feel warranted 
in laying down hard-and-fast rules in reference to the description of 
the various clinical manifestations of labyrinthitis, or as to the treat- 
ment. The student of this subject should first learn all he can about 
the anatomy, physiology, and functional tests of the labyrinth, and then 
study the clinical observations recorded in the literature, and, having 
mentally digested them, he is prepared to treat them with a relative, 
if not an absolute, degree of intelligence. If, in the following descrip- 
tions of the various types of labyrinth disease, the author should 
appear to speak too dogmatically, it may be said in extenuation that 
medical history is largely made up of dogmatism, to be repented of 
today and redogmatized tomorrow. 

Of all the forms of labyrinthitis, acute diffuse suppurative laby- 
rinthitis is attended by the most immediate and serious consequences. 
It always means permanent total deafness in the affected ear, and 
often the death of the patient. Hinsberg has estimated that 1 in 
every 100 cases of suppurative middle-ear disease develops into sup- 
purative labyrinthitis. Von Stein, in 420 cases, found suppurative 
labyrinthitis ten times, or in 2.2 per cent, of the cases. As many of 
the intracranial diseases are due to labyrinthitis, this disease becomes 
a subject of grave clinical importance. Labyrinthitis in any form is 
(926) 



GENERAL REMARKS ON LABYRINTHITIS 927 

not of itself dangerous. The danger lies in the intracranial compli- 
cations which are liable to occur. Of these diffuse meningitis (lepto- 
meningitis) is the most serious, as it has a death rate of nearly 100 
per cent. Cerebellar abscess has a death rate of more than 75 per 
cent.; hence the most important motive influencing the nature of the 
therapeutic measures to be adopted is to prevent the extension of 
the infectious process to the cranial cavity. This motive is apparently 
given a secondary place by some writers who advise waiting until 
actual intracranial involvement occurs before instituting radical 
remedial measures. Kerrison advocates waiting, in acute diffuse 
manifest labyrinthitis, for headache and continued high temperature 
before operating. Others advocate a radical exenteration of the mas- 
toid process and labyrinth as soon as complete deafness and a negative 
caloric reaction occur, claiming by this method of procedure, a reduc- 
tion of the death rate. Others contend that the labyrinth operation 
is of itself an added element of danger, as the brain, they say, is thereby 
exposed to infection. This claim is, it appears to me, not based upon 
either logic or observation. I am assuming that the operator is thor- 
oughly qualified, and that he performs the Hinsberg or some other 
equally good operation, by which the labyrinth is adequately opened 
for drainage, and that meningitis is not already present. 

While the other types of labyrinthitis are not of immediate danger 
to life, they are, nevertheless, possessed of the same potential dangers 
that are present in the acute suppurative manifest labyrinthitis; that 
is, they are all liable to become acute diffuse suppurative in type, in 
which even they present all the dangers of a primary diffuse suppura- 
tive labyrinthitis. In diffuse serous labyrinthitis, circumscribed laby- 
rinthitis, and perilabyrinthitis, a labyrinth operation is not usually 
indicated so long as each remains true to its type, but should they 
become converted into diffuse manifest suppurative labyrinthitis, the 
indications for operative treatment are identical with those of primary 
diffuse manifest suppurative labyrinthitis. 

The question seems therefore to resolve itself into the following: 
Is the death rate in acute diffuse suppurative labyrinthitis influenced by 
any method of operation; and if it is favorably influenced, or if it is 
unfavorably influenced by any method or operation, by which method is 
it either favorably or unfavorably influenced^ 

We can, perhaps, arrive at a more correct conclusion if we reason by 
analogy than if we reason from statistical data, as these are necessarily 
limited. We have learned through the reports of many cases of uncom- 
plicated chronic mastoiditis, that complete recovery is very favorably 
influenced by the proper operative technique. We have, furthermore, 
learned by experience that improved technique in mastoid surgery 
has advanced with experience, and that the number of cases requir- 
ing a second operation has correspondingly diminished. Fifteen years 
ago it was frequently reported through the literature that 25 per cent. 
of the radical mastoid operations failed to produce the desired results. 



928 THE EAR 

Experience and improved technique have reduced the failures to about 
5 per cent. Indeed, we can now effect cures in the same class of chronic 
disease by the various types of the modified radical operation. If 
the Jansen-Neumann and Hinsberg operations give good results now, 
further experience will improve the technique, and still further enhance 
the good results. 

Let me again emphasize certain elementary facts: (a) So long 
as a vestige of hearing is present the case is not one of acute diffuse 
manifest suppurative labyrinthitis, but is either circumscribed, serous, 
or some other type of labyrinthitis, and a labyrinth operation is contra- 
indicated. 

(b) When the deafness is complete, as shown by Barany's noise 
apparatus, the case is probably one of acute diffuse manifest suppura- 
tive labyrinthitis, though it may be diffuse serous labyrinthitis, as may 
be shown by the presence of caloric reaction, or the fistula symptom. 

(c) Complete loss of hearing and the absence of caloric and com- 
pression reactions in the affected ear means, therefore, that the patients' 
life is in jeopardy from impending meningitis or cerebellar abscess. 

(d) Meningitis and cerebellar abscess may be prevented by an 
early suitable operation, and the life of the patient spared. 

(e) If, on the contrary, we wait for signs of intracranial involvement 
before operating, the death rate in operated cases will be nearly 100 
per cent. 

The whole problem as it appears to me is this: An immediate diag- 
nosis of acute diffuse suppurative labyrinthitis followed by an imme- 
diate combined mastoid and labyrinth operation will prevent a fatal 
issue in many of the cases; whereas a delay of from three to seven 
days, for the purpose of detecting the advance of the infectious process 
to the cranial content, will result in the subsequent death of many of 
the patients who might otherwise have been saved. 



CIRCUMSCRIBED LABYRINTHITIS 

Circumscribed labyrinthitis is an infectious inflammatory disease of 
a circumscribed area of either the vestibular or the cochlear portion 
of the labyrinth, or of both together. The vestibular apparatus (utricle, 
saccule, and semicircular canals) is more often affected than the cochlea. 
Occasionally both the vestibular and cochlear apparatuses are involved. 
Circumscribed vestibular-apparatus disease is a less dangerous process 
than circumscribed cochlear disease, or circumscribed vestibulo- 
cochlear disease. When the cochlea is the site of a circumscribed 
inflammation it is much more liable to become diffuse and terminate in 
the complete destruction of the whole labyrinth. This is especially 
true if the initial infection in the tympanum is virulent, and invades 
the cochlea. If the infection is mild, and slowly perforates into the 
cochlea it mav become localized indefinitelv. 



CIRCUMSCRIBED LABYRINTHITIS 929 

The external limb of the horizontal canal is the most frequent site 
of circumscribed labyrinthitis, either with or without fistula; fistula 
is, however, usually present. Circumscribed labyrinthitis, localized 
in the cochlea has been studied histologically (microscopically) more 
frequently than the same process limited to the horizontal canal. 
This is so because circumscribed cochlear labyrinthitis more often 
goes to postmortem (Fig. 494). 

Fig. 494 




Circumscribed labyrinthitis. (Ruttin, Annals of Otology, Rhinology, and Laryngology.) 

Etiology. — The usual cause of this disease is a chronic suppurative 
otitis media, mastoiditis, or cholesteatoma. Fistula of the bony wall of 
the labyrinth usually occurs over the membranous horizontal canal as 
it lies in the zone of stress (the aditus ad antrum) where the purulent 
secretion passes over it flowing from the antrum into the middle- 
ear cavity, and where the cholesteatoma causes pressure necrosis of 
the external labyrinth wall. The lymph spaces around the exposed 
membranous labyrinth subsequently become infected, but become 
walled off by protective granulation tissue. The infection may also 
extend into the membranous canal, in which event the process is liable 
to become diffused through the entire labyrinth, though it, too, may 
become walled off by round-cell infiltration. Fistula may also occur 
at the oval and round windows, the promontorium, and at the tym- 
panic mouth of the Eustachian tube. Bony fistula in the last four 
positions may involve the membranous and nervous cochlea, and the 
condition become much more serious, as the entire labyrinth may 
become involved. 

The Rationale of the Symptoms. — The character of the symptoms 
of circumscribed labyrinthitis are largely determined by the following 
factors : 

(a) The presence of fistula. 

(b) The absence of fistula. 
59 



930 THE EAR 

(c) The location of the fistula. 

(d) The stimulation of the crista?. 

(e) The inhibition of the crista?. 

(/) The circumscribed area of the labyrinth involved. 

The Presence of Fistula. — The presence of fistula is usually attended 
by the fistula symptom when either compression or aspiration of air 
in the external auditory meatus is performed (see Fistula Test). The 
condensed or rarefied air either compresses or expands the mem- 
branous labyrinth at the point of bony fistula, and thereby causes a 
molecular movement of the endolymph in the semicircular canals, in 
a direction either from the utricle through the ampulla to the canal, 
or from the canal through the ampulla to the utricle. The direction 
of the impact of endolymph determines the direction of the nystagmus. 
If the impact is from the utricle through the ampulla to the canal, 
there is a weak nystagmus to the opposite side (Plate XXII) ; whereas 
if it is from the canal through the ampulla to the utricle, there is a 
stronger nystagmus to the same side (Plate XXI). If it is to the 
right by compression, it will be to the left by aspiration, and vice versa. 
Fistula symptoms (nystagmus upon compression or aspiration) may 
be negative (absent) even when fistula is present; that is, the endo- 
lymph may be coagulated and difficult to displace by either compression 
or aspiration, though in some cases of this type several forcible com- 
pressions of the bulb will elicit nystagmus. Fistula symptoms may 
also be absent or negative when the fistula is present, if the localized 
inflammatory process has destroyed the functional capacity of the 
crista nearest the fistula. Localized destruction of the crista? is, 
however, comparatively rare. 

The Absence of Fistula. — The absence of fistula in circumscribed 
labyrinthitis is more rare than the presence of fistula. It is readily 
conceivable, however, that localized infection and inflammation may 
become established in either the perilymph or endolymph spaces 
without fistula. Infection may occur through either the blood or 
lymph vessels. The absence of bony fistula is, of course, not attended 
by fistula symptoms (nystagmus) upon either compression or aspira- 
tion; that is, it is negative. If, therefore, there is a history of recurrent 
attacks of spontaneous nystagmus, vertigo, nausea, vomiting, and 
ataxia, and during the stage of quiescence fistula symptom cannot be 
elicited, fistula is probably not present. 

The clinical significance of "fistula symptom present," and of "fistula 
symptom absent" in circumscribed labyrinthitis is as follows: In 
those cases in which fistula symptom is present the inflammation is 
somewhat more liable to become diffuse than it is in those in which 
it is absent. 

The Location of the Fistula. — The influence of the location of the 
fistula upon the expression of the induced nystagmus during the periods 
of quiescence is quite characteristic, and the diagnostic and prognostic 
deductions to be drawn thereform are often of the greatest value. If 
for example, the bony fistula is in the external arm of the right hori- 



CIRCUMSCRIBED LABYRINTHITIS 931 

zontal canal, the compression test will cause a flow of endolymph 
from the canal through the ampulla to the utricle. The impact of 
the endolymph is therefore against the canal half of the crista ampul- 
laris of the horizontal canal. The impact excites a nervous impulse 
in the hair cells of the crista which is transmitted through the right 
Deiters' nucleus to the adductor muscles of the right eye, and the 
abductor muscles of the left eye (Hoegyes' law), thereby causing a 
slow conjugate movement of both eyes to the left. This is imme- 
diately followed by a corrective impulse in the right cortical centre, 
which is transmitted to the antagonists of the muscles stimulated 
by the vestibular nervous impulse, and the eyes are quickly turned 
to the right; that is, the compression induces nystagmus to the 
same side stimulated, or to the right in the example cited (Plate XXI). 
Aspiration would, of course, induce nystagmus to the opposite or 
left side. The significance of these reactions is that the fistula is in 
the horizontal canal, a relatively safe location. If, on the contrary, 
compression is accompanied by induced nystagmus to the opposite 
side (left in this instance), it signifies a bony fistula anterior to the 
ampulla of the horizontal canal, in either the oval window, round 
window, or promontorium (Plate XXII). As previously stated, fistula 
in either of these regions is more often followed by diffuse suppurative 
labyrinthitis and total destruction of the static-auditory labyrinth. 
And, furthermore, diffuse suppurative labyrinthitis is often attended 
or followed by either meningitis or cerebellar abscess, and death. The 
direction of the fistula nystagmus upon compression is, therefore, of 
important diagnostic and prognostic value. « 

The Cristse Either Stimulated or Inhibited. — We will now turn our 
attention to the spontaneous nystagmus, present during one of the 
so-called vestibular attacks, which occur at more or less frequent 
intervals during the course of circumscribed labyrinthitis. In most 
cases the direction of the spontaneous nystagmus is to the affected 
side, which signifies that the crista? are stimulated, i. e., the "signs 
of stimulation disharmony" are present, as in induced nystagmus. 
In other cases the spontaneous nystagmus is to the unaffected side, 
signifying an inhibition or destruction of the impulses from the crista 
of the semicircular canal of the affected labyrinth, i .e., signs of destruc- 
tion disharmony are present. Inhibition of function signifies a greater 
involvement of the crista (the end-organ of the vestibular nerve) than 
does stimulation of function. Stimulation disharmony is, however, 
more often present (Plates XXI and XXII). 

The Area of Involvement is Circumscribed. — As the name of this type 
of labyrinthitis signifies only a circumscribed area of the labyrinth is 
involved. The symptoms are therefore characteristic of the circum- 
scription. If, for example, the whole vestibulocochlear apparatus is 
functionally destroyed, as in acute diffuse manifest suppurative laby- 
rinthitis, or the fifth degree of diffuse serous labyrinthitis is present, the 
spontaneous nystagmus will be to the opposite side (Plate XXV), and 
the hearing totally destroyed in the affected ear. In circumscribed 



932 THE EAR 

labyrinthitis, the spontaneous nystagmus (during the vestibular attacks) 
is usually to the same side (Plates XXI and XXII), and the hearing is 
but slightly or moderately diminished. Even in those cases in which 
the spontaneous nystagmus is to the opposite side, or to either side 
when looking to one side and then to the other, the hearing is but 
slightly or moderately diminished. The presence of any degree of 
hearing and spontaneous nystagmus to either or both sides is charac- 
teristic of circumscribed labyrinthitis. In serous labyrinthitis of a 
lesser degree than the fifth (see Serous Labyrinthitis), there may be 
some hearing present, but the spontaneous nystagmus is always to the 
unaffected side (Plate XXV), that is, the signs of destruction disharmony 
are always present. 

Symptoms. — Having discussed the rationale of the symptoms of 
circumscribed labyrinthitis, only a brief discussion of the symptoms in 
relation to the course of the disease will be necessary. 

Circumscribed labyrinthitis is usually attended by recurring attacks 
of giddiness upon stooping, quickly turning the head, jarring move- 
ments, as in cycling or motoring over rough roads, jumping on and 
off cars, or other sudden and unaccustomed movements. What is of 
greater diagnostic significance in these patients is that in addition to 
the dizziness excited by sudden movements, the vestibular attacks 
occurring independently of sudden or jarring movements of the head. They 
occur while the patient is sitting in a chair, or lying quietly in bed, or 
even while asleep. During these attacks, vertigo, giddiness, nausea, 
and spontaneous nystagmus are present, and are more violent and of 
longer duration than the attacks occurring upon sudden jarring move- 
ments. The spontaneous nystagmus may be to either or both sides. 
It is rotatory in character, and is made more manifest by turning the 
eyes to the quick component. The turning and caloric tests usually 
show both labyrinths to be functionating normally, though when the 
endolymph is coagulated the reaction may be absent or difficult to 
induce in the affected ear. After the " attack" the symptoms disappear 
and only recur with the succeeding "attacks." During the vestibular 
attacks the spontaneous nystagmus may be to the diseased side or 
to the normal side, or to both sides, when looking to the outer angle 
of either eye, though it is usually stronger to the diseased side. The 
hearing may be impaired but not destroyed; indeed, it may be very 
good. The hearing distance for the whispered voice is generally 
reduced to from \ to 1 meter, though in a case reported by Ruttin, 
it was 8 meters. The turning and caloric reactions are usually well 
pronounced. Fistula symptom is usually present, though it may be 
absent, as when the endolymph is coagulated, and when cholestea- 
tomatous plugs or granulations block the fistula. When the fistula 
symptom attending the compression test is absent it is difficult to 
make a diagnosis. In many instances in which the attacks are of 
short duration the condition is one of circulatory disturbance rather 
than of circumscribed labyrinthitis. This is especially true of those 
cases in which the attacks only occur upon sudden or jarring move- 



CIRCUMSCRIBED LABYRINTHITIS 933 

ments of the head. In true circumscribed labyrinthitis the patients 
have the attacks independent of such movements of the head, as 
when lying quietly in bed. 

Subjective noises are present in about one-third of the cases. In 
50 cases reported by Ruttin they were present in 17 and only severe 
in 2. 

Diagnosis. — (a) Vestibular symptoms occur in attacks at more or 
less frequent intervals and are excited by sudden or jarring movements 
of the head and body. During the vestibular attacks the spontaneous 
nystagmus may be either to the affected or to the unaffected side, or 
to both sides. 

(b) The intervals between the attacks are free from vestibular 
symptoms. 

(c) The hearing is impaired but not destroyed. 

(d) Caloric reaction is present (positive) in the affected ear. 

(e) Turning reaction is present (positive) in the affected ear. 

(/) Fistula symptom (nystagmus upon compression) is usually 
present or positive in the affected ear, though it may be absent. 

(g) Vertiginous attacks occur when the patient is physically quiet 
(very significant). 

Indications. — A mastoid operation may be indicated. The labyrinth 
should not be operated, as hearing is present, and in the event of the 
disease becoming acute diffuse manifest suppurative labyrinthitis, 
ample warning of impending meningitis is usually given by the occur- 
rence of complete deafness and the loss of all vestibular reaction to 
the various tests. When this occurs an immediate operation upon 
the labyrinth should be considered, though serous labyrinthitis is still 
a possibility. During the mastoid operation in cases complicated by 
known circumscribed labyrinthitis, great care should be exercised to 
avoid probing, or other meddlesome interference with the fistula and 
inner wall of the tympanum and antrum. There is always a strong 
temptation to probe the fistula and observe the slow movement of 
the eyes to the opposite side. By thus probing the fistula the circum- 
scribed area of inflammation may be disturbed, and a diffuse induced 
serous or suppurative labyrinthitis excited. Under general anesthesia 
the quick component of the nystagmus will not occur, as the cortical 
centre from which the impulse arises is paralyzed by the anesthetic; 
hence, upon probing the eyes remain fixed in the position of the 
slow component. The cerebellar centrums (Deiters', Bechterew's 
and angular nuclei) belong to the lower order of reflex organs and 
are not paralyzed by the anesthetic; whereas the cortical reflex area, 
being a higher order of reflex centre, is paralyzed by the general 
anesthetic. 

Treatment. — Do a radical mastoid operation, if required, and avoid 
meddlesome interference with the fistula and inner wall of the tym- 
panum and antrum. Do not curette these areas. Do* not remove 
granulations from the inner wall of the tympanum. Do not operate 
upon the labyrinth. 



934 THE EAR 



ACUTE DIFFUSE SEROUS LABYRINTHITIS 

Acute diffuse serous labyrinthitis is a condition superimposed upon 
a preexisting circumscribed labyrinthitis, or it occurs as a primary 
labyrinth disease secondary to acute aural disease, or to surgery of 
the mastoid. Some cases are therefore preceded by the vestibular 
attacks of circumscribed labyrinthitis, and intervals of freedom from 
vestibular symptoms (see Circumscribed Labyrinthitis). Others have 
a sudden onset with very severe vestibular disturbances, known as 
the "signs of destruction disharmony." These cases often closely 
resemble acute diffuse suppurative labyrinthitis, though some vestibular 
reaction can usually be elicited by the fistula or caloric test. 

Etiology. — Diffuse serous labyrinthitis may be caused as follows: 

1. It may be secondary to a circumscribed labyrinthitis, and it 
sometimes occurs without a known cause. That is, it appears to occur 
spontaneously, or following a cold in the head. It is sometimes classified 
as a secondary labyrinthitis because it is secondary to circumscribed 
labyrinthitis. 

2. It is sometimes caused by a severe inflammatory reaction follow- 
ing the mastoid operation, the patient being previously affected by 
circumscribed labyrinthitis. When thus caused the symptoms appear 
at from the first to the fifth day after the mastoid operation. This 
is sometimes called diffuse serous induced labyrinthitis. 

3. It may also follow circumscribed labyrinthitis, when a direct 
injury of the labyrinth is inflicted during a mastoid operation. When 
thus caused the symptoms appear at once, that is, when the patient 
awakens from the anesthetic he is giddy, nauseated, and has spon- 
taneous nystagmus. The "signs of destruction disharmony" are 
present. 

4. It sometimes follows acute otitis media in which the inflammation 
extends through the intact labyrinth wall. 

5. Edema of the middle ear sometimes extends into the labyrinth. 

6. Chronic otitis media occasionally causes serous labyrinthitis by 
extension. 

7. The absorption of the toxic products of the bacterial activity 
in the middle ear and mastoid cells is probably the most common cause 
of serous labyrinthitis (Fig. 495). 

Symptoms. — When the diffuse serous exudate occurs there is a 
sudden arrest of function, i. e., there is a rapid and marked diminution 
of hearing upon the affected side, and nystagmus to the sound side. 
Nausea, vomiting, vertigo, and disturbance of equilibrium are also 
present in varying degrees of severity. The patient involuntarily lies 
on his sound side, as this compels him to look toward the slow compo- 
nent of the nystagmus when the eyes are open; that is, he looks away 
from the pillow in the direction of the slow component of the spontaneous 
nystagmus, and this position of the eyes suppresses the vertiginous 
symptoms. These symptoms are often severe, lasting from three to 



ACUTE DIFFUSE SEROUS LABYRINTHITIS 



935 



five days. The labyrinth is, however, not usually destroyed, as is 
shown by the subsequent restoration of its functions. The tonus of 
the affected static labyrinth is either greatly diminished or totally 
lost for a few days. Therefore the unaffected static labyrinth pre- 
dominates in tonus impulses, and the spontaneous nystagmus is to the 
normal side (Plate XXV). As the serous exudate is absorbed the 
nystagmus and vertiginous attacks subside and finally disappear. 

Pig. 495 




>B 





Diffuse serous labyrinthitis. Section through the vestibule. A, facial nerve; B, stapes; C, utricle 
intact; D, exudate in the cysterna perilymphatica. (Ruttin, Annals of Otology, Rhinology, and 
Laryngology.) 



Indeed, if the serous exudate persists for many days or a few weeks, 
extralabyrinthine compensation would cause the symptoms to dis- 
appear. The serous type may become suppurative and cause complete 
destruction of the labyrinth and eventuate in meningitis or abscess, 
and death. This termination is comparatively rare. I have observed 
several cases in the latent stage in which the hearing in the affected ear 
was completely destroyed, but in which some vestibular response to the 
caloric test remained. Such cases are generally classified as having 
been serous labyrinthitis of the fifth degree. It has also been stated 
that serous labyrinthitis has no latent stage. If these cases were 
serous in the acute stage, this disease has a stage of latency just 



936 THE EAR 

as truly as has the diffuse manifest suppurative type of labyrinthitis. 
For practical clinical purposes these cases will be classified as sequellse 
of a diffuse serous labyrinthitis. 

Severe vertigo, nausea, vomiting, and loss of equilibrium occur at 
the onset of the disease and gradually diminish in intensity, The 
hearing is the first function to disappear. The patient instinctively 
lies upon his sound side, as this causes him, when his eyes are open, 
to look away from the pillow toward the slow component of the nystag- 
mus, a position of the eyes which inhibits the vestibular symptoms. 
Xo amount of persuasion will induce him to lie upon his affected side 
during the height of the vestibular symptoms, as this posture would, 
when the eyes are open, cause him to look toward the quick component 
of the nystagmus, and thus intensify the vestibular symptoms. 

Should the patient attempt to stand with his heels approximated, 
head erect, and face forward, he would fall toward the diseased side, 
that is, toward the slow component of the nystagmus. With his face 
toward the right shoulder (assuming the right labyrinth to be diseased) 
he would fall backward in the direction of the slow component. With 
his face toward the left shoulder, he would fall forward, the direction 
of the slow component of the nystagmus, while the head is in this 
position. 

Spontaneous nystagmus is rotatory and to the sound side (Plate 
XXVII) . The hearing is more impaired than the vestibular function, 
which, according to Ruttin, is because the perilymph of the cochlea 
(functional element) is more superficially located than the endolymph 
(functional element) of the vestibular apparatus. The hearing is 
greatly impaired, and, indeed, in most cases is temporarily abolished 
in the affected ear. So long as the hearing is completely sup- 
pressed it is difficult to differentiate the disease from acute diffuse 
manifest suppurative labyrinthitis, in which the hearing is permanently 
destroyed. In diffuse serous labyrinthitis some static function is, 
however, usually more or less retained, and when this is the case the 
disease is readily distinguished from diffuse manifest suppurative 
labyrinthitis. In most cases the restoration of hearing is almost to 
normal. The reactions to the turning, fistula, and caloric tests are 
more or less modified, and in severe cases are temporarily abolished. 
When all reactions are abolished it becomes difficult, indeed, to differ- 
entiate it from acute diffuse manifest suppurative labyrinthitis, as 
the symptoms are identical. In the course of a few days, however, 
the hearing returns, and the reactions to the caloric, turning, and 
fistula tests are reestablished except in very severe cases. This, of 
course, is never true of diffuse suppurative manifest labyrinthitis, as, 



PLATE XXVII 

There has been sudden and complete loss of hearing in the right ear. The warm 
caloric test induces nystagmus to the same (right) side. The cold caloric test 
induces nystagmus to the opposite (left) side, showing the disease to be serous 
labyrinthitis rather than diffuse suppurative labyrinthitis. 



PLATE XXVII 



srfc* ^ 1Z0° SEROUS 

LABYRINTHITIS 




18° COLD 
120° WARM 



The Calorie Tests in Serous Labyrinthitis. 



PLATE XXVIII 



SLOVv 




The Turning Tests in Serous Labyrinthitis. 



ACUTE DIFFUSE SEROUS LABYRINTHITIS 937 

in that disease, both the static and auditory labyrinths are completely 
destroyed. Whereas, in diffuse serous labyrinthitis the functions of 
the labyrinth are for a time partially or wholly suppressed, but the 
labyrinth is not usually destroyed, though complete destruction of 
the cochlea, and almost complete destruction of the static labyrinth 
may occur. In the subsequent course of such cases the patient may 
have recurrent attacks of giddiness. When the functions of the 
labyrinth are completely suppressed the case is liable to terminate 
in diffuse suppurative manifest labyrinthitis, or at least in complete 
destruction of the cochlea. 

Every case of acute diffuse manifest labyrinthitis with apparent loss 
of cochlear and static function should be carefully tested before deciding 
upon operation, as it may be serous in type, and may recover with 
restitution of function. In severe diffuse serous labyrinthitis, one or 
more static reaction is usually, though not always, present. In diffuse 
manifest suppurative labyrinthitis all static and auditory functions 
are permanently lost. In order to detect the presence of possible 
remaining vestibular function, the tests should be methodically applied 
as follows: 

1. Make the caloric test. If the reaction is negative the hearing, 
as a rule, is also destroyed (Plate XXVII). The static labyrinth may 
not be completely destroyed but may retain some function in which 
even the ratio of the nystagmus by the turning tests to the right and 
left will be more than 1 to 2 (see Plate XXV). 

2. If there is no reaction to the caloric test, make the turning test 
(Plate XXVIII). This may or may not induce reaction. If the static 
labyrinth is totally destroyed, turning toward the sound ear will induce 
nystagmus of one-half the duration of that induced by turning toward 
the affected side. 

3. If the turning test is negative make the fistula test, which arouses 
the strongest reaction of all the tests, and if fistula is present, and the 
case is one of diffuse serous labyrinthitis, there is a positive reaction, 
i. e., nystagmus is elicited. If this and the other tests fail to induce 
nystagmus, and the patient is totally deaf in the affected ear, the case 
is probably one of diffuse suppurative labyrinthitis, though if fistula is 
absent the diagnosis cannot be thus positively made; it may be of the 
serous type. 

Serous labyrinthitis, even when severe, rarely invades the intra- 
cranial content. 

The loss of function usually occurs in the following order: 

1. Hearing. 

2. Caloric reaction. 

3. Turning reaction. 

4. Fistula reaction. 



PLATE XXVIII 

Sudden and complete loss of hearing. Turning to the right induces after-nystag- 
mus to the left. Turning to the left induces after-nystagmus to the right; hence 
the disease is serous rather than diffuse suppurative labyrinthitis. Spontaneous 
nystagmus is to the opposite or healthy side. 



938 THE EAR 

When serous labyrinthitis is due to a reaction inflammation follow- 
ing a mastoid operation the "signs of destruction disharmony" follow 
in from twelve to seventy-two hours. When, however, it is due to 
direct injury of the labyrinth during the mastoid operation, the " signs 
of destruction disharmony" appear at once, i. e., as soon as the patient 
recovers from the anesthetic. 

The "signs of destruction disharmony" are nystagmus, nausea, 
vomiting, vertigo, and disturbance of equilibrium, and they are due 
to the sudden loss of function on one side, thus leaving a preponderance 
of nervous impulses from the sound labyrinth. If the right labyrinth 
is affected the impulses from this labyrinth are suddenly suppressed, 
and remain normal in the sound or left labyrinth. The left labyrinth, 
therefore, pulls the eyes (slow component) to the right, and the quick 
component to the left or sound side immediately follows. The nystag- 
mus is to the sound side. The patient has a tendency to fall to the 
affected side, the direction of the slow component when looking straight 
ahead. When the face is turned over the right shoulder, the fall is 
backward. When the face is turned over the left shoulder the fall 
is forward. 

In disease of the labyrinth it is practically universal to find the 
"signs of destruction disharmony" present (except in circumscribed 
labyrinthitis); whereas in testing normal ears, we elicit the "signs 
of stimulation disharmony." 

Ruttin gives the following table of symptoms as typifying the five 
degrees of severity of this disease: 

Table of Degrees of Severity in Serous Labyrinthitis. — Always with 
less severe degrees of serous inflammation, one or the other of the 
functions of the labyrinth is present. Loss of function is customary 
in the following order: 

1 . Hearing reaction 
Caloric reaction 
Turning reaction 
Fistula symptoms 

2. Hearing Absent. 
Caloric reaction ") 
Turning reaction > Present. 
Fistula symptoms J 

3. Hearing | Absent 
Caloric reaction J 
Turning reaction \ 
Fistula symptoms f " resen t- 

4. Hearing ^\ 
Caloric reaction r Absent. 
Turning reaction ) 
Fistula symptoms Present. 

5. The fifth degree, namely, total loss of function is impossible to 
differentiate from suppurative labyrinthitis, except by waiting for the 
return of the cochlear and vestibular functions. If the functions of 



Present. 



ACUTE DIFFUSE SUPPURATIVE MANIFEST LABYRINTHITIS 939 

the affected labyrinth do not return, the disease is probably acute 
diffuse manifest suppurative labyrinthitis. If they do return, it is a 
case of diffuse serous labyrinthitis. If, in a given case of circum- 
scribed labyrinthitis, symptoms of diffuse labyrinthitis suddenly arise, 
the diagnosis of diffuse serous labyrinthitis depends upon the demon- 
stration of at least one function of the labyrinth. 

Indications. — The radical mastoid operation is indicated after the 
manifest symptoms disappear. The labyrinth should not be operated. 
The mastoid operation may be postponed until the acute symptoms 
of serous labyrinthitis have subsided as there is no particular danger of 
extension to the cranium. 

The same symptoms prevail in the induced as in diffuse serous secon- 
dary labyrinthitis, though they are more severe in character. In the 
induced cases there is no history of previous vertiginous attacks, as in 
serous secondary labyrinthitis (secondary to injuries, etc.). The 
vestibular attack is sudden and severe and the vertigo lasts longer 
than in secondary serous labyrinthitis. This is due to the fact that 
compensation has not been previously established, as it has in the 
diffuse serous secondary labyrinthitis, in which there were numerous 
vestibular attacks preceding the serous exudate. The cases secondary 
to circumscribed labyrinthitis have become more or less immune, 
i. e., compensation has been more or less established; whereas in the 
induced cases compensation has not occurred. As previously stated, 
the symptoms are somewhat in proportion to the suddenness and 
completeness of the suppression of function. The symptoms gradually 
abate in intensity and finally disappear in from one to four weeks. 

Treatment.— The mastoid operation with rest in bed may be per- 
formed to relieve the mastoiditis and otorrhea. Curettage of the 
antrum and tympanic cavity should be studiously avoided. Do not 
operated upon the labyrinth. 



ACUTE DIFFUSE SUPPURATIVE MANIFEST LABYRINTHITIS. 

Diffuse suppurative manifest labyrinthitis is characterized by 
sudden deafness in the affected ear, giddiness, nausea, vomiting, loss 
of equilibrium, and spontaneous nystagmus to the sound side (signs 
of destruction disharmony). 

Etiology. — The causes of this form of labyrinthitis are acute mas- 
toiditis, chronic mastoiditis, cholesteatoma, tuberculosis, syphilis, 
etc. It may follow circumscribed labyrinthitis, and diffuse serous 
secondary labyrinthitis. The causation is, however, more far-reaching 
than this; it often includes disease of the faucial and pharyngeal tonsils. 
I have had three cases which presented the following general history: 
(a) Acute tonsillitis, followed by (b) acute otitis media and mastoid- 
itis; (c) during the acute stage of otitis media deafness, giddiness, 
nausea, and ataxia occurred, i. e., acute diffuse suppurative laby- 
rinthitis occurred; (d) a few days later meningitis developed; and 
finally (e) death supervened. The role of tonsillitis and adenoids in the 



940 THE EAR 

production of the labyrinth disease, though an indirect one, is of first 
importance, as disease of the tonsils and adenoids lies at the very foun- 
dation of aural disease, and as nearly all deaths of otitic origin are 
due to intracranial disease, we are, in the last analysis, driven to the 
deduction that indirectly disease of the tonsil and adenoids is the 
cause of labyrinthitis, meningitis, sinus thrombosis, and brain abscess, 
with their attendant high mortality (Fig. 496). 

Fig. 496 




D 

Manifest purulent labyrinthitis. A, oval window, pus broken through; B, drum membrane- C, 
promontorium; D, round window broken through. (Ruttin, Annals of Otology, Rhinology, and Laryn- 
gology.) 

Symptoms. — The symptoms of acute diffuse manifest suppurative 
labyrinthitis have their origin almost altogether in the sudden loss of 
balance or tonus between the two labyrinths. The suddenness of the 
loss is the determining factor. In exceptional cases the loss of tonus 
is so gradual that it is symptomless. In acute diffuse manifest suppura- 
tive disease of the labyrinth the whole labyrinth, cochlear and ves- 
tibular portions, are almost instantly destroyed. If the destruction 
should occur in both labyrinths simultaneously there would be no 
vestibular symptoms, as spontaneous nystagmus, ataxia, etc. As 
the destruction is usually limited to one side, or at least, does not 
often occur simultaneously on the two sides, there is a modified tonus 
in the affected labyrinth. The crutch (vestibular apparatus) being 
suddenly removed from one set of muscles, their antagonists act 
without their accustomed restraint, producing movements of the eyes, 
body, and extremities. A corrective reflex impulse is thereby excited 



ACUTE DIFFUSE SUPPURATIVE MANIFEST LABYRINTHITIS 941 

in a cortical reflex centre, and the eyes are quickly turned in the opposite 
direction, and incoordinate movements of the extremities occur. These 
movement-cycles are known as nystagmus and reaction movements. 
When spontaneous nystagmus occurs in disease of the ear, it is usually 
due to the sudden removal or diminution of the function of one vestibu- 
lar apparatus. The labyrinth spaces are so small that the absorption 
of septic matter therefrom does not materially affect the temperature. 
The temperature present is, therefore, due to the absorption of toxic 
material from the middle ear and mastoid process rather than from 
the labyrinth; or if sinus thrombosis or meningitis is present it may 
be due to either of these conditions. In any event it is not a sign of 
progression within the labyrinth, but is a sign of continued infection 
extraneous to the labyrinth. 

The symptoms of acute diffuse manifest labyrinthitis are generally 
referred to as the "signs of destruction disharmony;" whereas the 
symptoms of certain cases of circumscribed labyrinthitis and of con- 
gestion of the labyrinth are known as the "signs of stimulation dis- 
harmony." 

The "Signs of Destruction Disharmony." — The "signs of destruction 
disharmony" are: 

(a) Spontaneous nystagmus to the sound ear. 

(b) Nausea and vomiting. 

(c) Giddiness. 

(d) The sense of external objects floating around the patient in the 
plane of the nystagmus, and in the direction of the slow component 
of the nystagmus. 

(e) Ataxia or incoordinate movements of progression. 

The foregoing are also the "signs of stimulation disharmony" with 
the following difference, i. e., the spontaneous nystagmus is to the 
diseased side or ear. In diffuse suppurative labyrinthitis, say of the 
right ear, there is a total loss of static function in that ear; whereas 
there is normal static function in the left ear. Before the destruction 
the tonus was the same in both labyrinths; we will assume it to 
have been 20 potentialities. After the destruction of the right laby- 
rint the tonus in the right labyrinth was 0, and in the left it remained 
normal, 20 potentialities. The nervous impulses from the left laby- 
rinth being the stronger would therefore turn the eyes slowly to the 
right, according to Hoegyes' law, namely, Deiters' nucleus sends motor 
impulses to the adductors of the eyes of the same side, and to the 
abductors of the eye of the opposite side, thereby producing a con- 
jugate movement of both eyes to the opposite side (slow component 
of the nystagmus). The cortical correction hi the reverse direction 
immediately follows; hence spontaneous nystagmus to the healthy 
side occurs. If the nystagmus were due to stimulation of the eristic 
of the affected labvrinth the nystagmus would be toward the affected 
side (Plate XX). 

Deafness. — The deafness in this disease is usually sudden and com- 
plete in the affected ear. It occurs simultaneously with the "signs of 



942 THE EAR 

destruction disharmony/ ' and is due to the same pathological process, 
i. e., purulent inflammation extending throughout the cochlea. The 
deafness may not be obvious to either the patient or his companions, 
as the hearing in the other ear is not affected. Therefore, when the 
"signs of destruction disharmony" occur, the ears should be examined 
as soon as the condition of the patient permits. The signs of destruc- 
tion disharmony at the onset are often very severe and compel the 
patient to go to bed. After several hours or a few days they usually 
subside sufficiently to allow the ears to be examined for vestibular 
function and hearing; indeed, the hearing may be tested earlier in 
the course of the disease. The test consists of the application of 
Barany's noise apparatus to the unaffected ear and addressing the 
affected ear with an increasingly louder voice, up to the shouting voice, 
or until it is ascertained whether or not hearing is present in that ear 
(see Functional Tests of Hearing). In this type of labyrinth disease 
the hearing is totally destroyed; hence, if the signs of destruction 
disharmony and total deafness are present, the disease is probably, 
though not certainly, acute diffuse manifest suppurative labyrinthitis. 
I say it is not certainly diffuse manifest suppurative labyrinthitis, 
because these symptoms may also be present in the fifth degree of 
diffuse serous labyrinthitis. Still another factor must be taken into 
account before a diagnosis can be made; indeed, two more factors 
must be considered, namely, (a) the presence or absence of vestibular 
reaction to artificial stimulation; (b) the subsequent restoration of 
hearing in some degree. 

(a) If vestibular reaction in the affected ear is demonstrable the 
disease is not diffuse suppurative labyrinthitis but is serous laby- 
rinthitis. 

(b) If the hearing is restored at any future time the disease was 
not diffuse suppurative labyrinthitis but was serous labyrinthitis. 

These conclusions are based upon the fact that diffuse manifest 
suppurative labyrinthitis is invariably attended by the complete 
destruction of the cochlear function, though it is conceded that some 
vestibular function may occasionally remain, as this organ has more 
resistance to degeneration from infection than the cochlea. If, there- 
fore, the hearing never returns, and no vestige of vestibular function 
can be shown, the disease is diffuse suppurative in type; whereas, if 
any degree of hearing is restored the disease should be regarded as 
having been serous in character throughout its course. 

Vestibular Reaction. — Vestibular reaction is usually abolished in 
the affected ear, though it may be present in exceptional cases for 
the reason expressed in the preceding paragraph. For clinical purposes 
all cases with total destruction of hearing in which the vestibular 
function is not totally destroyed may be classified as diffuse serous 
labyrinthitis of the fourth degree, though it is quite probable that some 
of them are suppurative in character. Thus classified such cases are to 
be treated non-surgically unless meningitis or cerebellar abscess subse- 
quently develop. That the law in reference to the greater vulnerability 



ACUTE DIFFUSE SUPPURATIVE MANIFEST LABYRINTHITIS 943 

of the cochlea is not absolute was illustrated by a case reported recently 
by Dr. Ewing W. Day. This case had total destruction of the vestibular 
function and retained the cochlear function. The exceptional case 
does not, however, disprove the rule. Vestibular reaction is shown 
by the use of the caloric and fistula tests in the affected ear. As spon- 
taneous nystagmus is already present, vestibular reaction can only 
be shown by increasing or diminishing the intensity of the spontaneous 
nystagmus. If some vestibular function remains, and the cold caloric 
test is applied to the affected (say right) ear, there will be a downward 
flow of endolymph in the superior canal, and the impact of the endo- 
lymph will be against the canal half of the crista ampullaris. This 
causes a nervous impulse to be given off which traverses the nerve 
tract (red) marked 78° in Plate XXVII, through which the impulses are 
carried to the adductors of the left eye and the abductors of the right 
eye, thereby causing a slow conjugate movement of both eyes to the 
right. 1 This is immediately followed by a corrective movement of both 
eyes to the left, the quick component of the induced nystagmus. The 
impulse cycles thus aroused augment those already being expressed in 
the spontaneous nystagmus, hence the nystagmus present is increased 
in intensity (see Plate XXVII). If the warm caloric test is applied to 
the affected ear the nervous impulses will traverse the paths shown by 
the two blue lines marked 120° in Plate XXVII, and will cause a slow 
conjugate movement of both eyes to the left. This is immediately 
followed by a corrective movement of both eyes to the right, the quick 
component of the induced nystagmus. The nystagmatic movements 
thus induced are antagonistic, i. e., in the opposite direction, to the 
spontaneous nystagmus, hence it diminishes the intensity of the spon- 
taneous nystagmus. Indeed, it may entirely suppress it for twenty to 
thirty seconds, or during the life of the induced antagonistic impulses. 
When vestibular reaction is shown by the caloric tests as described 
above, and the deafness is complete, there is some doubt as to the 
nature of the pathologic process present. It is probably diffuse serous 
labyrinthitis. If, during the subsequent course of the disease the 
hearing returns, the disease is surely of the serous variety, whereas, if 
the hearing is totally and permanently abolished the process was 
probably diffuse suppurative labyrinthitis. Whatever the nature of 
the pathologic process the prognosis is more favorable than if the 
caloric reactions were not induced. The indications for treatment 
would also be materially modified; that is, an operation would be 
contra- indicated. If, however, caloric reactions were not demon- 
strable, the prognosis would be more grave, and an immediate opera- 
tion should, at least, be seriously considered. If for any reason a mas- 
toid operation is required the inner wall of the tympanum and aditus 
ad antrum should be closely inspected for fistula, and if found the 
labyrinth should also be operated. If fistula is absent, the labyrinth 
may be left without operation, though according to some authorities 

1 This result may also be attributed to- inhibition of the right crista, leaving balance of potentiality 
on the left side. 



944 



THE EAR 



Fig. 497 



SLOW COMPONENT 
PUICK COMPONENT 




Barany's pointing test. 

the labyrinth should in such cases be operated if mastoid operation is 
performed. Only further experience and observation can settle this 
question. 

Finally, it should be reiterated, that when caloric reaction is 
present and the deafness is complete the disease is in all probability 



ACUTE DIFFUSE SUPPURATIVE MANIFEST LABYRINTHITIS 945 

diffuse serous labyrinthitis rather than diffuse suppurative manifest 
labyrinthitis. 

Temperature. — Elevation of temperature gives no information as 
to the progress of disease within the labyrinth. As previously stated, 
the labyrinth spaces are too small, and the osseous walls too dense to 
allow the absorption of enough septic material to affect the tempera- 
ture. Whatever elevation of temperature may be present is due to 
the inflammation extraneous to the labyrinth. It is due to either otitis 
media, mastoiditis, sinus thrombosis, meningitis, abscess, etc., and not 
to the labyrinthitis. If this is true the elevation of temperature affords 
no information as to either the nature or progress of the labyrinthitis. 
It may, however, afford information as to the indications for surgical 
interference; that is, it may with the other symptoms present indicate 
either meningeal irritation or actual meningitis, and thus aid in deter- 
mining the advisability of a labyrinth operation. 

The Position of the Patient ivhile in Bed. — During the initial period 
of the vertiginous attack, previously referred to as the " signs of destruc- 
tion disharmony," the patient instinctively lies with his head so placed 
upon the pillow that when he opens his eyes he looks toward the slow 
component of the spontaneous nystagmus. With this position of the 
eyes the nystagmus and other vertiginous phenomena are either dimin- 
ished in intensity, or altogether suppressed. The patient is thereby 
made more comfortable. If, however, he should lie so that when his 
eyes are open he is compelled to look toward the quick component 
of the nystagmus, the nystagmus and other accompanying vertiginous 
symptoms would be aggravated and the patient rendered most uncomfort- 
able. He, therefore, voluntarily and insistently lies upon the side of the 
face toward which the quick component of the nystagmus is directed. 

The Pointing Reaction. — The pointing reaction of Barany is based 
upon the phenomenon that, when an individual is affected with either 
pronounced induced or spontaneous vestibular nystagmus, he will, 
when the eyes are closed, point toward the slow component of the 
nystagmus with either hand. When, therefore, he points to the slow 
component it is normal for vestibular disease, i. e., it indicates vestibular 
disease. If, however, he points in the opposite direction, or varies 
the direction of pointing in successive trials at the same sitting, it is 
abnormal for vestibular disease, and is suggestive of cerebellar disease. 
Furthermore, the pointing reaction in cerebellar disease only applies 
to the hand or arm of the diseased side (see Pointing Reaction Test and 
Fig. 497). 

Headache. — Headache is usually present in acute diffuse manifest 
suppurative labyrinthitis, but it is not as severe or as localized as in 
cerebellar disease. 

Tinnitus Aurium. — Tinnitus aurium of varying degrees of intensity 
is present in more than 30 per cent, of the cases. Occasionally it is very 
severe, even during the latent stage (see Diffuse Latent Labyrinthitis). 

The course of acute diffuse manifest suppurative labyrinthitis is deter- 
mined by the time required to establish extra-labyrinthine compensa- 
60 



946 THE EAR 

tion. This varies from one to four weeks. The establishment of 
extralabyrinthine compensation is signalized by the subsidence of the 
spontaneous nystagmus and the reaction movements of the body and 
extremities. The reaction movements consist of nausea and vomiting, 
and ataxia. When the spontaneous nystagmus and reaction move- 
ments cease to be manifest under ordinary conditions of life the disease 
is called diffuse latent suppurative labyrinthitis. There are, then, no 
manifest vestibular symptoms. They can only be aroused by special 
unaccustomed body movements/ as in the turning test, sudden stooping, 
jarring movements, etc. 

The onset of acute diffuse manifest suppurative labyrinthitis is 
characterized by a sudden and severe attack or seizure of spontaneous 
rotatory nystagmus to the unaffected side, nausea, vomiting, giddiness, 
the sense of surrounding objects whirling around the patient in the 
plane of the nystagmus, vestibular ataxia; and if he attempts to stand, 
he falls toward the slow component of the nystagmus. If the right 
labyrinth is destroyed he falls to the right when facing straight ahead. 
If he turns his face over his left shoulder he falls forward. If he turns 
his face over his right shoulder he falls backward. These reactions are 
known as the "signs of destruction disharmony," and they gradually 
abate in intensity and disappear altogether in from a few days to a 
few weeks. They are severe enough for a few hours or days to confine 
the patient to his bed. At the onset he instinctively lies upon the 
sound ear as this compels him, when the eyes are open, to look toward 
the slow component of the nystagmus, which diminishes the intensity 
of the nystagmus and reaction movements, and renders his condition 
much more tolerable. 

The hearing in the affected ear is immediately, totally, and forever 
destroyed, as is also the physiological irritability of the vestibular 
apparatus. Total deafness in the affected ear can be shown by the use 
of Barany's noise apparatus (see Functional Tests of the Ear). 

The caloric tests, if used in the affected ear, would show no vestibular 
reaction, as the vestibular apparatus is destroyed. 

The fistula test would also yield a negative result for the same 
reason. 

If, however, these tests are applied to the unaffected ear during 
the height of the spontaneous nystagmus they would yield positive 
reactions. The slow component of the spontaneous nystagmus (ves- 
tibular element) is rotatory and to the affected (right) side, and the 
quick component (cortical element) is rotatory and to the opposite, or 
unaffected left side. The application of the cold caloric test to the 
normal ear would induce a slow movement of the eyes to the unaffected 
side and a quick corrective movement to the affected side, and as each 
of these induced reactions is in the opposite direction to those of the 
spontaneous nystagmus, the intensity of the spontaneous nystagmus 
would be temporarily diminished or abolished. If the warm caloric 
test is applied the induced reaction would be in consonance with the 
spontaneous nystagmic movements, and the spontaneous nystagmus 



ACUTE DIFFUSE SUPPURATIVE MANIFEST LABYRINTHITIS 947 

would therefore be increased in intensity. The same tests may be 
applied to the affected ear, and if vestibular reaction is aroused the 
case is either one of serous labyrinthitis or cerebellar disease. 

These tests need not be applied except when in doubt as to the 
diagnosis. It sometimes happens in cerebellar abscess or tumor that 
the nystagmus is to the opposite side as in acute destruction of the 
labyrinth, and the diagnosis becomes an important matter. Under 
these circumstances the tests may be made to clear the diagnosis. 

If, however, acute cerebellar abscess is located on the right side, the 
side of the suppurative otitis media, and causes spontaneous nystag- 
mus to the same side, and reaction movements, the warm caloric 
test, applied to the affected ear would induce nystagmus which would 
increase the spontaneous nystagmus already present, as shown in 
Plate XXVII. The nystagmus would be diminished in intensity if the 
cerebellar nystagmus were directed, contrary to rule, to the unaffected 
side. The same reactions would be obtained if the disease were diffuse 
serous labyrinthitis, with partial suppression of vestibular function 
on the affected (right) side, though the difference in intensity of the 
spontaneous nystagmus would be less pronounced, as the crista? in 
this affection are inhibited, not normally sensitive, as they would be 
in cerebellar abscess. Another factor to be taken into consideration 
in the differential diagnosis between acute diffuse manifest serous 
and suppurative labyrinthitis and cerebellar abscess or tumor is the 
increasing or diminished intensity of the spontaneous nystagmus. In 
labyrinthitis it rapidly diminishes in intensity and disappears within a 
few days or weeks; whereas, in cerebellar disease it increases in inten- 
sity or continues indefinitely without recession. These difficulties 
of differentiation can but rarely arise, as total deafness is exceptional 
in abscess of the cerebellum, unless either diffuse serous or suppurative 
labyrinthitis is also present. The nystagmus of cerebellar origin may 
not be manifest until opaque glasses are applied. 

The Elevation of Temperature. — The elevation of temperature is 
due to the inflammatory process outside of the labyrinth, and not to 
the process within the labyrinth, as the labyrinth spaces are too small 
and the osseous walls too dense to permit enough septic absorption to 
materially affect the temperature. Continued elevation of temperature, 
therefore, is not per se an indication of the progression of the infection 
through the labyrinth to the meninges and brain. It may, however, 
show a continued virulency of inflammation extraneous to the laby- 
rinth, either extra- or intracranially. The prognosis is, however, there- 
by rendered correspondingly more grave. If the elevation of tem- 
perature continues, and is associated with severe headache, meningitis 
may be present; and if these symptoms are attended by a reversal in 
the direction of the spontaneous nystagmus, which is due to central 
stimulation rather than peripheral (labyrinthine) stimulation, meningitis 
is quite probable. Operation upon the labyrinth now becomes impera- 
tive and should be done at once. 

Prognosis. — The prognosis of acute diffuse manifest suppurative 
labyrinthitis is quite grave, as meningitis or cerebellar abscess may 



948 THE EAR 

complicate it, or occur as a later phenomenon during the period of 
latency (diffuse latent suppurative labyrinthitis). Labyrinthitis is 
not of itself a serious disease. Death results from the complications 
and sequelae. 

Treatment. — The treatment consists in (a) preventing the exten- 
sion of the infection from the labyrinth to the meninges and brain, 
and (b) the drainage of the infected suppurating area of the meninges 
and brain should they be present. 

The Prevention of the Extension of the Infection to the Meninges and 
Brain.— If any one would satisfactorily determine the safest and surest 
way to protect the meninges and brain from infection during the 
course of acute diffuse manifest suppurative labyrinthitis he would 
render a service of the highest order to the human race. Various 
procedures have been advocated and some of them tried with more 
or less success, but none of them have been used in a sufficiently 
large number of cases to warrant their unqualified endorsement. Indeed, 
no one has presumed that any method of treatment can ever be univer- 
sally successful. The hope is that some method of treatment will be 
found which will reduce the present mortality rate, and, perhaps, this 
has already been measurably accomplished. Of the methods of treat- 
ment which have been more or less successfully used for the prevention 
of the extension to the meninges and brain, the following are worthy 
of mention and discussion. 

1. Urotropin. — Urotropin has for several years been advocated as of 
therapeutic value at the inception of meningitis, and more particularly 
as a prophylactic measure. That it is of great value, is, I think, hardly 
proved, though it has appeared to act favorably in some instances. 

2. Absolute Quiet by Fixation. — Sheibe has advocated the fixation 
of the head by means of plaster bandages applied to the head and 
shoulders, though I understand some of his reported cures by this 
method of treatment afterward died and went to postmortem. Not- 
withstanding this, the idea is good and contains food for reflection. 
During the height of the attack the patient should be placed in bed 
and absolute physical quiet enforced, as even slight movements of the 
body and head might favor the spread of the infection to the sub- 
arachnoid spaces of the brain. For this reason no tests should be 
made that are not absolutely required to make the diagnosis. 

Surgical. — The question as to whether surgery of the labyrinth pre- 
vents the extension of the infection and inflammation to the meninges 
and brain is still an open one. Some authors claim that if the 
proper surgical measures are adopted immediately after the hearing is 
totally destroyed, meningitis and brain abscess will rarely complicate 
or follow acute diffuse manifest suppurative labyrinthitis. In other 
words, they claim a much lower mortality rate may be obtained by 
prompt operation than by waiting for intracranial symptoms before 
operation. 

Other authors of equal standing claim that to operate during the 
acute manifestations, or as soon as deafness is established, adds to 



DIFFUSE LATENT SUPPURATIVE LABYRINTHITIS 949 

the liability of intracranial extension, and that the safer procedure is 
to watch the symptoms, and, when signs of meningeal irritation, as 
continued elevation of temperature, severe headache, etc., supervene, 
to operate the labyrinth. Furthermore, if the patient passes through 
the acute disease and emerges safely into the latent type, operation 
may then be performed with greater safety, etc. 

If there is a question as to the disease being cerebellar abscess, and 
this cannot be determined, the labyrinth operation may be performed, 
and if after this the nystagmus and signs of destruction disharmony 
continue indefinitely the disease is undoubtedly cerebellar. 

The foregoing is a brief summary of the two great schools of thought 
upon this subject. It is very difficult to determine which is the nearer 
correct in its position. Reasoning by analogy I should conclude that 
the first procedure will better conserve life, provided the proper type 
of labyrinth operation is performed, and the technique of the operation 
is skilfully executed. In the absence of a thorough knowledge of the 
various operative procedures and of a technical operator, the second 
or 'waiting and watching" program would be the safer procedure. (See 
Indications and Surgery of the Labyrinth in the following chapter.) 



DIFFUSE LATENT SUPPURATIVE LABYRINTHITIS 

Etiology. — The etiology of the disease is identical with that of acute 
diffuse manifest suppurative labyrinthitis, as it is but the sequela or 
latent stage of that disease (see etiology of acute diffuse manifest 
suppurative labyrinthitis) . 

Symptoms. — The symptoms of this disease are due to the total 
destruction of both the vestibular and cochlear apparatuses in the 
affected ear and to the partial or complete compensation of vestibular 
function (Plate XXV) . If compensation of extralabyrinthine vestibular 
function is complete the disease is, insofar as subjective phenomena 
are concerned, almost symptomless; that is, the patient does not suffer 
from either spontaneous nystagmus or the "signs of destruction dis- 
harmony." His only subjective symptoms are total deafness in the 
affected ear, and the phenomena incidental to the purulent otorrhea. 
If extralabyrinthine compensation is not complete sudden movements of 
the head and looking toward the opposite side will produce nystagmus. 

The objective symptoms are those that may be induced by the 
various functional tests of the ear, i. e., successive turnings to the 
right and then to the left would give vestibular reactions in the ratio 
of 2 to 1 (Plate XXV), and the caloric reactions would be negative in 
the affected labyrinth. 

Deafness. — The hearing in the affected ear is completely and forever 
lost. The completeness of the deafness in the affected ear may be 
shown by placing Barany's noise apparatus in the unaffected ear, 
and, while it is in action, addressing the patient's affected ear with 
increasing loudness up to the shouting voice. If the instrument is 



950 THE EAR 

properly applied it will shut out all hearing from the sound ear; hence, 
if the loud voice of the examiner is not heard, the affected ear is shown 
to be totally deaf; whereas, if the patient hears the voice, the deafness 
is not complete (see Barany's Noise Apparatus Test). 

Purulent Discharge. — The purulent discharge differs in no way from 
that of simple chronic otorrhea and mastoiditis. If a fistula of the 
promontorium is present the secretion may be observed discharging 
through it. Granulations may also be seen around the fistulous 
opening. 

Fistula Symptom. — Fistula symptom, i. e., reaction to the compres- 
sion test, is absent (negative) even when a fistula is present. This is 
due to the total destruction of the cristas of the affected vestibular 
apparatus. Should fistula symptom be present (positive) doubt is 
aroused as to the nature of the primary acute process preceding the 
latent stage, or disease, though it is quite conceivable that a diffuse 
suppurative process may not destroy all vestibular function, as this 
organ is more resistant than the cochlea. Positive fistula symptom 
should, however, lead the surgeon to regard the disease as probably 
being serous labyrinthitis. 

Caloric Reaction. — Caloric reaction is absent or negative, as the 
crista? of the vestibular apparatus are wholly destroyed; the possible 
exception being those cases in which the preceding acute diffuse sup- 
purative process did not wholly destroy the vestibular apparatus. 
Total deafness in the involved ear would not, in the presence of caloric 
reaction, adequately support the assumption that these cases were 
primarily suppurative rather than serous in character. 

Turning Reaction. — The turning reaction varies in diffuse latent 
suppurative labyrinthitis according to the period of time which has 
elapsed since the acute diffuse manifest suppurative stage. That is, 
it varies with the degree of compensation that has taken place. It is 
customary to say that compensation has occurred when, as a matter of 
fact, there is only partial compensation, that is, spontaneous nystagmus 
and the "signs of destruction disharmony" are no longer present 
under ordinary conditions of body movements, though they may be 
induced by slight extraneous stimulations, as sudden stooping move- 
ments, sudden jarring movements, etc. The fistula and caloric tests 
do not cause stimulation of the affected labyrinth in this disease, as 
they act upon a dead labyrinth. The turnings act upon the unaffected 
labyrinth, no matter what the direction of turnings may be, and 
measure with some degree of accuracy the amount of destruction and 
compensation present (Plate XXV). 

We will assume the patient to be affected with diffuse latent sup- 
purative labyrinthitis in the right ear, and that the turning test was 
made three months after the period of latency was established. He 
was placed in a revolving chair and turned ten times, with the head 
erect, to the right or toward the affected ear, and suddenly stopped. 
Horizontal induced after-nystagmus to the left or opposite side is 
observed over the opaque glasses. It continues for about twelve 



DIFFUSE LATENT SUPPURATIVE LABYRINTHITIS 951 

seconds. After allowing the patient to rest for five or ten minutes he 
was turned ten times, with the head erect, to the left, and the eyes 
observed over the rims of the opaque glasses worn by the patient. 
Induced after-nystagmus of six seconds' duration was induced. While 
extralabyrinthine compensation has occurred, as shown by the absence 
of spontaneous nystagmus and "signs of destruction disharmony/' 
actual vestibular compensation has not occurred. As time goes on 
actual vestibular compensation seems to take place, and as it occurs 
the extralabyrinthine compensation seems to be replaced by it (Plate 
XXVI). Extralabyrinthine compensation is relative rather than abso- 
lute. Vestibular compensation is almost absolute. Extralabyrinthine 
compensation is acquired in from one to four weeks, whereas, vestibular 
compensation is established only after the lapse of several years. 

We will now assume that four years after the first test the same 
patient was subjected to the same tests, i. e., turning to the right 
ten times, and turning to the left ten times, and the after-nystagmus 
was noted after each test as before. In this instance, after the turnings 
to the right, the after-nystagmus endured eleven seconds, and after 
the turning to the left it endured eight seconds, thus showing an 
approach toward equality of tonus in the two labyrinths. 

We will now assume that eight years after the first, and four years 
after the second test, the patient was subjected to the same turning 
experiments, and that in this instance the after-nystagmus induced 
by turnings to the right endured twelve seconds, and after turnings 
to the left they endured eleven seconds. The tonus in the two 
opposing halves of the crista ampullaris of the horizontal canal of the 
unaffected ear is almost equal; indeed, it is as nearly equal as is found 
in persons with normal labyrinths, the difference being the shorter 
duration of the after-nystagmus after turning to either the right or 
the left (Plate XXVI). The extralabyrinthine compensation seems to 
have been gradually replaced by the vestibular or labyrinthine com- 
pensation. Whatever the explanation may be, it has been shown by 
Ruttin that, in cases of very long standing, almost complete vestibular 
compensation occurred, and that the extralabyrinthine compensation 
recedes as the vestibular compensation progresses. 

Differential Diagnosis. — The following conditions may simulate 
diffuse latent suppurative labyrinthitis and should be carefully differ- 
entiated from it: 

1. Hysteria sometimes simulates labyrinthitis though only in a 
superficial way. The nystagmus is not present in diffuse latent sup- 
purative labyrinthitis though it may be in hysteria. If present in 
hysteria it is not of the vestibular type, i. e., it does not have a quick 
and slow component, etc. The membrana tympani is either normal 
or it may be diseased. The hearing is either normal or, if ear disease 
is present, it may be impaired but not entirely lost, as in latent laby- 
rinthitis. If disturbance of equilibrium is present the body may fall 
in any direction; there is neither rule nor certainty in what direction 
the patient will fall; whereas, in labyrinth disease he always falls in 



952 THE EAR 

the direction of the slow component of the nystagmus. If, with the 
face straight ahead, and the slow component to the right, the patient 
will fall to the right; with the face directed over the left shoulder the 
patient will fall forward; with the face over the right shoulder he will 
fall backward. In a hysterical case the direction of the face would 
exert no definite influence upon the direction of falling. 

2. Disease of the Eighth Nerve. — Disease of the eighth nerve may 
develop independently of middle-ear disease, hence the vertiginous 
attacks due to a disturbance of the vestibular portion of the eighth 
nerve with an apparently normal middle ear should suggest disease 
of the eighth nerve. An important exception to this would be meta- 
static involvement of the labyrinth, especially for mumps. In disease 
of the eighth nerve (retrolabyrinthine disease involving the eighth 
nerve) only one division of the nerve is usually involved. That is, 
there is involvement of the vestibular branch alone, which is attended 
with vertigo, nausea and vomiting, loss of equilibrium, and nystagmus, 
while the hearing is unaffected; or the auditory division is affected 
and there is loss of hearing, but no vestibular symptoms are present. 
In true diffuse labyrinthitis both divisions of the eighth nerve are 
always affected, and deafness and vestibular symptoms attend the. 
destructive process. 

In these cases Ruttin has employed bilateral simultaneous caloric 
and galvanic tests, the caloric test giving the comparative suscepti- 
bility of the two static labyrinths to stimulation, while the galvanic 
test gives the comparative irritability of the two vestibular nerves and 
centrums. 

3. Polyneuritis (Syphilis) of the Eighth and Facial Nerves. — This con- 
dition is characterized by an attack of vertigo, nausea, nystagmus 
to the affected side, loss of equilibrium, deafness, and facial paralysis. 
The ear may appear to be normal. This condition simulates seques- 
trum of the labyrinth in which the facial may be involved, though in 
sequestrum the vertiginous attacks are absent, but upon inquiry the 
fact of their existence some time previously may be elicited. The 
Wassermann test in these cases is usually positive. 

4. Cerebellar Disease. — It sometimes happens that after the surgical 
removal of one labyrinth the nystagmus which at first was directed 
to the sound side became directed to the operated side. This is a sign 
of intracranial involvement, and the changed direction of the nystag- 
mus is due to direct stimulation of Deiters' nucleus of the diseased 
side. Previous to this phenomenon the labyrinth on the affected side 
was inhibited or destroyed and nervous impulses did not emanate 
from that side. Upon the inception of the cerebellar disease the stimu- 
lous (toxic, congestion) is applied directly to Deiters' nucleus of the 
affected side and produces spontaneous nystagmus to the diseased 
side, or in a reverse direction to that which previously existed. The 
nystagmus due to the labyrinthitis was caused by the total suppression 
of nervous impulses from the diseased labyrinth, whereas the nystag- 
mus due to the cerebellar disease was caused by the excessive nervous 
impulses from the diseased side. 



CHAPTER LII 

SURGERY OF THE LABYRINTH 

Indications for the Labyrinth Operations. — 1. There is at present 
no well-defined consensus of opinion as to the exact indications for 
the surgical drainage and exenteration of the labyrinth. Some hold 
that the total loss of hearing in acute diffuse manifest suppurative 
labyrinthitis is a positive indication for the labyrinth operation. Others 
contend that in such cases one should wait for indications of meningeal 
irritation, as severe headache, continued elevation of temperature, 
restlessness, etc., before doing a labyrinth operation, or, if these do not 
develop, that you should wait until the latent stage is established, as 
it is then safer to operate. In support of this view they cite cases that 
have recovered without the occurrence of meningitis, or cerebellar 
abscess. The opponents of these indications for the labyrinth opera- 
tion in reply cite many cases that, while waiting, developed diffuse 
suppurative meningitis or cerebellar abscess and died. They also 
state that if meningitis develops about 98 per cent, of them die in 
spite of a labyrinth operation, and that of all cases, operated as soon 
as hearing is lost and before meningitis develops, a large per cent, of 
them recover. They claim the labyrinth operation in the hand of an 
otologist skilled in diagnosis and surgical technique does not of itself 
constitute a serious procedure. The seriousness attending such cases 
often lies in the failure to make a diagnosis sufficiently early or before 
meningitis sets in. A further danger in waiting for signs of impending 
meningitis lies in the fact that there are no well-recognized symptoms 
of "impending meningitis." When such so-called symptoms are 
present they not infrequently indicate the "actual presence" of diffuse 
suppurative meningitis. In these cases, therefore, it is often too late 
to do a labyrinth operation with any reasonable hope of saving the 
life of the patient. Another fact of great importance is that the further 
extension of the infection toward the meninges is not signalized by 
an increase in the vestibular symptoms as increased spontaneous 
nystagmus, vertigo, nausea, ataxia, etc. The vestibular apparatus is 
destroyed and incapable of being further destroyed, hence cannot again 
give rise to vestibular symptoms. In view of the foregoing considera- 
tions I am inclined to believe that the safety of the patient is better 
conserved in acute diffuse manifest suppurative labyrinthitis, with 
total destruction of the auditory and static labyrinths, by a labyrinth 
operation. If, however, there is a remnant of either the auditory or 
static functions remaining, it is safe to wait, as the further sudden 
destruction of these functions will be signalized by an increase in the 

( 953 ) 



954 THE EAR 

intensity of the vestibular symptoms, thus constituting a warning of 
impending danger in ample time to perform a labyrinthine operation. 

2. In diffuse latent suppurative labyrinthitis, i. e., the stage of qui- 
escence following acute diffuse manifest suppurative labyrinthitis in 
which total destruction of hearing and static function occurred during 
the acute stage, a labyrinth operation may be more safely done than 
it can in the acute manifest form of the disease, that is, the mortality 
rate due to the operation per se, will be less than it is with operation 
in the acute stage of the disease. Indeed, the death rate should be 
almost nil after operation on this type of labyrinthitis. The object of 
the operation is, of course, to prevent the subsequent occurrence of 
meningitis and cerebellar abscess. Some authors advocate waiting 
until this stage to operate, as the operation will be much safer then. 
They apparently forget that, while waiting Macawber-like for some- 
thing to "turn up," meningitis or brain abscess often develops, and the 
patient dies. It is to prevent these possible deaths that the labyrinth 
operation is recommended. 

The patient, however, having been so fortunate as to pass through 
acute destructive suppurative labyrinthitis without serious conse- 
quences, is, nevertheless, still in grave danger of the occurrence of 
meningitis or other serious intracranial sequela. 

In view of the almost total absence of danger from the labyrinth 
operation in latent diffuse labyrinthitis, and the danger that may occur 
if the operation is not performed, a labyrinth operation should be 
advised as an early remedial measure. 

3. In acute diffuse serous labyrinthitis there is usually no likelihood 
that the cranial content will become involved, hence a labyrinth opera- 
tion is contraindicated. Furthermore, the hearing is usually restored 
to nearly normal or as near normal as before the disease. This, of 
course, constitutes another contraindication to operation. 

4. In circumscribed labyrinthitis, either with or without fistula symp- 
tom, the labyrinth operation is positively contraindicated, as the 
hearing is but slightly impaired, and static function is only disturbed 
at intervals, and warning will be given in the form of sudden deafness, 
ataxia, etc., of impending danger to the brain. Should sudden deafness 
and vestibular symptoms develop, a critical examination should be 
made at once, and if total destruction has occurred an immediate 
operation should be seriously considered. The disease is now con- 
verted into either an acute diffuse serous labyrinthitis, or an acute 
diffuse manifest suppurative labyrinthitis. If it is serous, operation 
is contraindicated. If acute diffuse manifest suppurative labyrinthitis, 
operation may be advised. If not performed the patient should be 
kept as nearly "fixed" in bed as possible, as even slight movements 
of the head might cause further extension of the pathologic process. 
Upon the appearance of headache or other signs of meningeal irritation 
advise a labyrinth operation, though it is probably too late to head off 
meningitis. It is just such "waiting," however, that may throw dis- 
credit upon the labyrinth operation. 



SURGERY OF THE LABYRINTH 955 

The Merits of the Various Labyrinth Operations. — In arriving at 
conclusions as to the comparative merits of the various labyrinth 
operations we must constantly bear in mind the following facts: 

1. The general purposes for which the various operations are 
performed. 

2. The scope of each operation. 

3. Whether the labyrinthitis is simple or complicated by some intra- 
cranial pathological process, or whether a sequestrum is present. 

4. If in doing a mastoid operation a suppurative labyrinthitis is 
found (pus oozing from a perforation in the promontorium), the opera- 
tion should be modified to meet the unexpected complication. 

The general purposes for which the operations are performed are 
(a) drainage of the labyrinth spaces, and (6) the drainage of the menin- 
geal or subarachnoid spaces. 

(a) If only the drainage of the labyrinth spaces is necessary, the 
Hinsberg operation is admirable for the purpose. The Hinsberg 
operation in the University Hospital at Breslau has been attended 
by a death rate of only 4 per cent. This is certainly a good showing 
and speaks favorably for the operation, especially in view of the 
fact that it is the simplest operative procedure in vogue. In this 
operation the external limb and ampulla of the horizontal canal, 
the vestibule, and lower whorl of the cochlea are opened. In the 
Neumann and Richards operations all of the canals are either 
exenterated or laid open. As the canals communicate only with the 
vestibule, and the vestibule is freely opened in all types of labyrinth 
operation, it appears rational to expect no serious complication even 
though the canals are not exenterated or freely opened. We cannot, 
however, evade the issue that when meningitis is present none of 
the operations, excepting Neumann's, provides for the drainage of the 
meninges at the atrium of infection. It seems to me, therefore, that 
in choosing an operation this factor must be given due considera- 
tion. Neither the Hinsberg, Bourguet nor Richards operation drains 
the meningeal spaces. In all the vestibule and cochlea are opened, 
the vestibule very adequately, and the cochlea sufficiently to afford 
fair drainage. In Richards' operation the cochlea may be opened more 
freely than in either of the others, including Neumann's. Extensive 
exposure of the cochlea, however, is attended by considerable danger. 

(b) If it is also necessary to drain the meninges, neither of these 
operations is suited for the purpose. Some operation must be chosen 
that will do all that these operations accomplish, and in addition must 
drain the meninges at the atrium of infection. As this is nearly always 
situated at the intracranial orifice of the internal auditory meatus 
which conveys the eighth or auditory-vestibular nerve to the labyrinth, 
or on the posterior wall of the pyramid, it is necessary to perform an 
operation that drains the areas of meninges at the internal auditory 
meatus and posterior wall of the pyramid. As the meninges envelop 
the eighth nerve throughout the entire length of the internal auditory 
meatus to the area cribrosa, it is doubly necessary to open the internal 



956 THE EAR 

auditory meatus its whole length, should the meningeal infection 
traverse this route. The only operation fulfilling all these conditions 
is Neumann's. When, therefore, it is either suspected or known that 
meningitis has developed, Neumann's operation is the only one avail- 
able for this purpose. 

Richards' operation is a fine piece of dissection of the vestibule, 
semicircular canals, and cochlea, and is a more thorough operation 
than the Hinsberg or the Bourguet operation. It is more difficult to 
perform, and is attended by the greater danger of injuring the facial 
nerve and modiolus of the cochlea, and is on this account a less desir- 
able operation than the Hinsberg operation, which is, perhaps, the 
simplest labyrinth operation. The Bourguet operation accomplishes 
the same ends as the Hinsberg, though the technique is not so simple 
or well conceived. 

(c) If a sequestrum of the cochlea or any other portion of the laby- 
rinth is found, it should, of course, be removed. Some operators are 
content to extend the labyrinth operation under such circumstances 
only far enough to liberate the sequestrum, trusting to the protection 
of the granulation wall which has been formed. 

(d) If the surgeon should chance to perform a mastoid operation 
upon a case affected by suppurative labyrinthitis without having 
previously diagnosed it as such, and should find pus exuding from a 
fistula of the labyrinth, he should extend the operation so as to include 
the labyrinth, perhaps preferably by the Hinsberg method. If, how- 
ever, he suspects or knows that meningitis is also present, he should 
do the Neumann operation, or no operation. 

In view of these facts it is apparent that the otologist should not 
only be conversant with the indications for an operation, but he should 
also be familiar with the indications for a particular type of operation. 
It should be said, however, that in spite of all that is known, it will 
be impossible to always correctly judge as to the absolute wisdom of 
doing a labyrinth operation, and, if an operation is really necessary, 
it is not always possible to correctly determine the scope of the 
operation required to give the best results. 

It will doubtless require the accumulated experience and observa- 
tions of many years to decide either of these questions. In the mean- 
time each otologist should act in accordance with his best judgment 
and perfect a technique of diagnosis and operation, reporting his 
results for the benefit of other otologists. Only in this way will we 
be enabled to arrive at a satisfactory solution of this vexing problem. 
He should constantly bear in mind that he is dealing with a disease 
process which threatens life at its most vital centre, and should, 
therefore, carefully weigh all the phenomena and determine as nearly 
as he can the probable outcome in each case, with and without surgical 
intervention. He should also estimate the most favorable time in the 
course of the disease to operate. Furthermore, he should remember 
in formulating his indications for treatment of acute diffuse manifest 
suppurative labyrinthitis, that, though the death rate following opera- 



THE JANSEN-NEUMANN LABYRINTH OPERATION 957 

tion in the subacute or chronic latent stage is lower than in the acute 
manifest stage, it does not necessarily follow that he should always 
wait until the latent stage to operate. This would be false logic, as 
while waiting for latency to develop the patient may develop menin- 
gitis and die; whereas it is possible, and even quite probable, that 
an operation in the acute manifest stage would, in properly selected 
cases, prevent the development of meningitis, and save the life of the 
patient. 

I believe, therefore, that while an operation on the labyrinth should 
not always be done in acute diffuse manifest suppurative labyrinthitis, 
it should, however, always be most carefully considered in formulating 
the indications for treatment. I have endeavored in this section on 
labyrinthitis, to view the various phenomena and problems from a 
multitude of view-points so as to meet the many perplexities which 
confront the student of labvrinth disease. 



THE JANSEN-NEUMANN LABYRINTH OPERATION 

The Neumann operation is the same as the Jansen operation except 
that it goes one step farther and uncovers the eighth nerve (vestibulo- 
auditory nerve). That is, the internal auditory meatus is opened. 
The Neumann operation should be performed when meningitis is 
suspected or known to be present and has its atrium of infection 
through the internal auditory meatus, or through the posterior wall 
of the pyramid. The Hinsberg operation should be performed when 
the complicating meningitis is known not to be present. The Jansen 
and Neumann operations are essentially similar, with the aforesaid 
exception; hence they will be described together. 

Preliminary Measures. — The radical mastoid operation should first 
be performed (if it has not been done previously) as a preliminary 
step in all labyrinth operations, and the labyrinth operation should 
immediately follow. The projecting margins of the mastoid wound 
should be removed to give ample space for the instruments in the 
labyrinth. The tympanic mouth of the Eustachian tube should be 
curetted to free it of bleeding granulations and congested mucous 
membrane. Adrenalin should then be applied to stop the bleeding, 
as it is necessary to keep the operative field clear in the subsequent 
steps of the operation. 

First Step. — The outer and anterior bony wall of the lateral sinus 
should be removed with either a broad gouge (Alexander's No. 14) or 
with special rongeur forceps The thin bone anterior and superior to 
the lateral sinus, known as Trautmann's triangle, is then removed. 
This triangular area is bounded above by the roof of the mastoid 
cavity, posterior-inferiorly by the sigmoid portion of the lateral sinus. 
and anteriorly by the facial ridge, or rather a line extending from the 
anterosuperior angle of the mastoid wound to the inferior margin of 
the lower end of the lateral sinus. In removing the thin bone from 



958 THE EAR 

the lateral sinus and Trautmann's^ triangle, the dura should first be 
gently elevated, and the bone then removed with a broad, flat gouge 
and mallet, or a special rongeur forceps. Great care should be taken 
to avoid tearing the dura, as such an injury might lead to meningitis 
or brain abscess. If the dura is torn, the tear should be enlarged 
at the close of the operation and tincture of iodine applied. A small 
rent does not afford good drainage, whereas a large one does. The 
dura should be thus respected throughout the subsequent steps of the 
operation. 

In Fig. 498 I have shown a transparency of the labyrinth, which 
will act as a guide in exposing the canals and opening the vestibule 
in the subsequent steps of the operation. 

Second Step. — The next step of the operation consists in elevating 
the dura from the posterior wall of the pyramid preliminary to the 
removal of the three semicircular canals which are embedded in the 

Fig. 498 




Transparency showing the labyrinth which, when compared with the following steps of the 
Neumann operation, explains the rationale of the operation. 

pyramid or petrous portion of the temporal bone. The dura should 
be elevated from the posterior wall of the pyramid about one-half to 
one inch deeper than Trautmann's triangle. It should be elevated with 
a thin blunt-edged spatula or elevator down to the inner opening 
of the internal auditory meatus. As the saccus endolymphaticus is 
located in a slight depression on the posterior wall of the pyramid 
and is enveloped between reflections of the dura, there is some danger 
of tearing the dura at this point. To obviate this accident it may be 
necessary to cut the dural attachment of the sac to the bone with 
a scalpel. In other words, if the dura does not readily separate from 
the bone, the area of resistance should be scratched with the point of 
a scalpel, the point being directed against the bone rather than parallel 
with the posterior surface of it. Having thus freed the saccus endo- 



THE JANSEN-NEUMANN LABYRINTH OPERATION 



959 



lymphaticus, continue the elevation of the dura to the inner orifice of 
the internal auditory meatus. 

Fig. 499 




First step. The lateral sinus and Trautmann's triangle uncovered, and the two openings 
of the posterior canal opened. 

Third Step. — Having completed the elevation of the dura on the 
posterior wall of the pyramid, proceed to remove the semicircular 



Fig. 500 







Second step. Another chip of bone has been removed and the arch of the horizontal canal 
exposed, the three openings forming the angles of a triangle. 

canals. This is accomplished with a No. 10 or 14 Alexander gouge, 
the gouge being directed parallel with the surface of the posterior 



960 THE EAR 

and superior walls of the pyramid. The posterior wall extends prin- 
cipally inward and somewhat forward. The superior margin slopes 
slightly downward and supports the superior petrosal sinus, hence the 
gouge should be directed inward, forward, and slightly downward, to 
avoid injuring this sinus, as otherwise troublesome hemorrhage would 
result. The operator should, of course, first establish a clear mental 
image of the relation of the parts by studying the bones in situ in a 
skull (Fig. 498). Having placed the gouge at the proper angle, with 
its concave surface facing posteriorly, the posterior wall of the pyramid 
should be removed in shavings or thin chips. The gouge should be 
very sharp, as it will otherwise pursue an uncertain course through 
the bone and fracture it. It should be driven with sharp blows of a 
leather, wooden, or leaden mallet, as the bone is very dense and resistant. 
The first chip of bone may be about J by \ by ^t °f an mcn m dimen- 
sions. When the chip is freely separated by the gouge it should be 
removed with stout dressing forceps. The dura having been pre- 
viously separated from it, there should be little difficulty from this 
source. The rough edges of the fragment of bone may, however, 
catch against the roughened margins from which it is being detached 
and thus render its removal difficult. A little gentle manipulation, as 
twisting, etc., together with a firm pull will facilitate its removal. 
The chip should be inspected to see if the posterior canal has been 
cut through. If cut through the tip of its arch, an oblong groove will 
be present on its anterior surface. If the cut is more anteriorly the 
two limbs of the canal will be cut through and appear as two dark red 
oval or round openings (Fig. 499). These openings may also be seen 
in the posterior surface of the bony wound as well as on the chip of 
the bone. The openings serve as landmarks for the removal of the 
next chip of bone. 

The gouge should again be placed in position as before and another 
thinner chip removed and so on until the common canal of the posterior 
and superior canals and the external limb of the horizontal canal are 
sectioned. The opening of the horizontal canal should be situated 
between the other two openings previously mentioned, and more super- 
ficially in relation to the side of the head, the three openings forming 
the three angles of a triangle (Fig. 500). 

A small silver probe should then be introduced into the opening 
of the horizontal canal and passed into the vestibule. The direction 
taken by the probe should be noted, as the bone to be removed to 
open the vestibule envelops this limb of the horizontal canal (Fig. 501). 
A smaller Alexander gouge (No. 5 or 7) should be selected for the 
purpose and the bone removed. This stage of the operation brings 
the gouge in close proximity to the facial ridge and nerve, and great 
care must be exercised to avoid injuring the nerve. The gouge should 
undermine the nerve. Prying against the ridge should be studiously 
avoided. If the ridge is broken by prying or other traumatism the 
facial nerve will be injured and facial paralysis result. The location 
of the facial nerve should be carefully determined before opening 



THE J AN SEN-NEUMANN LABYRINTH OPERATION 



961 



the vestibule and the gouge located posteriorly and superiorly to it 
to avoid injuring it. One or two small chips of bone along the course 
of the external limb of the horizontal canal, the course of which is as 



Fig. 501 




Third step. Still more bone removed and a silver probe passed through the external limb 
of the horizontal canal into the vestibule. This guides to the vestibule. 



Fig. 502 




Fourth step. The vestibule exposed. The overhanging ledge of bone is removed. 

indicated by probing it, should expose the vestibule on its posterior 
aspect (Fig. 502). A probe passed through the oval window should 
pass out through the vestibule into the bony wound. 

Owing to their great vascularity, the canals when cut across appear 
as dark red or purple spots. 
6L 



962 



THE EAR 



This technique completes the static labyrinth portion of the Jansen- 
Neumann operation. If incipient meningitis is present or suspected, 
the internal auditory meatus should also be opened by extending the 



Fig. 503 




The gouge in place is ready to remove the promontory. 

bone wound deep enough to uncover the nerves in the internal auditory 
canal and thus establish drainage at the atrium of infection. This 
step is peculiar to Neumann's method of operating. 

Fig. 504 




Fifth step. The promontory removed, exposing the lower whorl of the cochlea. 



Fourth Step. — To expose the internal auditory canal which contains 
the eighth cranial nerve (vestibulo-auditory nerve) the Alexander 
gouges Nos. 7 to 10 are used. The posterior wall of the pyramid is 



THE JANSEN-NEUMANN LABYRINTH OPERATION 



963 



removed about one-quarter or three-eighths of an inch deeper than 
is done in the Jansen type of operation. The chips of bone should 
be about ^6 °f an mcn m thickness, or they may be thin shavings. 



Fig. 505 




First step, a, bone chiselled from above the horizontal canal, b, external arm of the 
horizontal canal. c, facial ridge. 

Fto. 50R 




Second step. The arrow points to the open external arm of the horizontal canal. This was 
opened by chiselling downward, removing the superior bony wall of the canal. 

If the dura is now retracted from the deeper portion of the wound 
the eighth nerve may be seen enveloped in a sheath composed of a 
reflection of the dura. 



964 THE EAR 

This completes the static-labyrinth portion of the operation. That 
is, the semicircular canals, vestibule, and internal auditory canal con- 
taining the auditory vestibular nerve have been exposed, and drain- 
age of these parts and of the meninges at the possible atriums of 
infection has been established. 

This field of operation lies posterior to the descending portion of the 
facial ridge. The remaining or cochlear portion of the operation lies 
anterior to the facial ridge and consists in exposing the cochlear spaces 
of the first or basal whorl of the cochlea. 

Fifth Step. — In the fifth step of the operation one-half of the lower 
whorl of the cochlea is exposed by the removal of the promontory of 
the inner wall of the middle ear cavity. Preparatory to doing this the 
anterior margin of the facial ridge should be removed, as it overhangs 
the tympanic cavity and interferes with the removal of the promon- 
tory (compare Figs. 507 and 508). A probe bent at a right angle passed 
under the projecting margin will show how much is to be removed. If 
more bone than projects is removed the facial nerve will be injured. 
Before removal the posterior margin of the middle-ear cavity is ragged 
and somewhat straight in general direction. After the projecting ledge is 
removed the outline of the cavity is converted into a symmetrical oval. 

The tympanic cavity being thus more fully exposed the tip of a 
flat No. 10 chisel or No. 10 Alexander gouge should be placed in the 
depression posterior to the promontory, i. e., between the oval and 
round windows, and, with a light blow of the mallet the promontory 
shaved off (Fig. 503). The gouge at first stands almost perpendicular 
to the plane of the inner wall of the tympanic cavity, though it is 
inclined as much backward as the facial ridge will permit. As it is 
tapped its cutting edge is allowed to glide forward and the shank of 
the instrument to incline more and more backward. . In this way the 
thin shell of bone forming the promontory is removed, and the lower 
half of the first whorl of the cochlea exposed (Fig. 503). 

To attempt to more deeply expose the cochlea would endanger the 
modiolus, which, if fractured, would allow the cerebrospinal fluid to 
escape and would provide a dangerous avenue to intradural infection. 
This completes the Jansen-Neumann labyrinth operation, though the 
wound remains to be dressed and closed as after the radical mastoid 
operation. 

The Closure of the Wound. — The plastic meatal flaps should be made 
as in the radical mastoid operation, but instead of using the deep 
anchor sutures as in the radical operation the meatal flaps should be 
sutured to the posterior surface of the auricular wound, having pre- 
viously dissected away all the redundant tissue from this aspect of the 
auricle (see mastoid operation, Balance's plastic flap). This method 
of disposing of the meatal flaps should be adopted instead of the deep 
anchor sutures, as the mastoid wound should not be completely closed 
as in the radical mastoid operation. 

The upper half or two-thirds of the mastoid incision should be 
sutured as in the radical mastoid operation, while the lower portion 



THE HINSBERG OPERATION 965 

should be left open for drainage and for inspection of the interior of 
the wound. If after five days no untoward symptoms have devel- 
oped, the edges of the skin may be freshened under cocaine anesthesia 
and closed with two or three stitches. 



THE HINSBERG OPERATION 

This operation consists in opening the horizontal canal and vestibule 

(a) above and behind the knee of the facial ridge, (6) opening the 
vestibule superior to the facial ridge, and (c) opening one-half of the 
lower whorl of the cochlea. The meninges are not exposed as in the 
Jansen-Xeumann operation. Inasmuch as it cannot always be deter- 
mined whether meningitis is impending or already present, this opera- 
tion would be inadequate in some cases. In those cases in which 
there is no meningeal complication it is an almost ideal surgical 
procedure. 

The Hinsberg operation should be preceded by the radical mastoid 
operation, the curettage of the tympanic orifice of the Eustachian 
tube, the application of adrenalin, and the chipping off of the 
overhanging ledge of bone from the anterior margin of the facial 
ridge. 

The stapes is then extracted and the oval window enlarged by 
breaking down the plate of bone between the oval and round windows. 

First Step. — The first step of the operation consists in opening 
the horizontal canal, which communicates with the superior portion 
of the vestibule. The ampulla of the horizontal canal is situated 
directly above the oval window and above and behind the knee of 
the facial ridge, and may generally be located by a slight ridge or 
convexity on the inner wall of the antrum (Fig. 505, 6). By means 
of a small probe bent at a right angle near its tip the roof of the vesti- 
bule may be delineated through the oval window. Having determined 
the limitations of the roof and the anterior and posterior walls of the 
vestibule, the opening of the ampulla of the horizontal canal should 
be begun. This is accomplished by chiselling away the spongy bone 
just above the superior aspect of the ampullary ridge (Fig. 505, a). 
The chisel should be flat, sharp, and small, as the bone should be 
removed in thin shavings. The upper part of the prominence of the 
horizontal canal should be removed until the ampulla? and canal 
are opened on their superior aspects. The lower part of the canal 

(b) should not be removed, as it is in close proximity to the facial 
nerve. Kerison advises a specially devised curette for this procedure. 
Having opened the ampulla and canal, a bent silver probe should 
be introduced through the enlarged oval window and through the 
ampullary opening in the roof, as shown in Fig. 507. The area of 
the vestibule should again be determined with the probe, and the 
ampullary opening just made should be enlarged, usually in a down- 
ward and forward direction, until the vestibule is uncovered from 



966 



THE EAR 



above (Fig. 507). The vestibule should be examined for necrosed 
bone, granulations, etc., and if present they should be gently removed 
with a small curette. 

Fig. 507 




A bent probe is passed from the oval window upward through the exposed horizontal canal 

and vestibule. 



Fig. 508 




Third step, a, the overhanging lip of bone, marked x in Fig. 507, has been removed to make 
it possible to use the gouge in removing promontorium. b, the promontorium. 

Second Step. — The projecting ledge of bone (Figs. 507 and 508) should 
be removed with a No. 10 Alexander gouge to make room for the 



THE HINSBERG OPERATION 



967 



gouge in removing the promontorium in the cochlear portion of the 
operation. 



Fig. 509 




The gouge in place preparatory to removing the promontorium. 
Fig. 510 




Fourth step, a, the promontorium removed, exposing the cochlea, b, the cochlea exposed, 
c, the horizontal canal exposed, d, the facial ridge. 

Third Step.— A No. 10 Alexander gouge is placed in position as shown 
in Fig. 509, engaging the posterior margin of the promontorium below 
the oval and round windows. The gouge at first stands almost per- 



968 THE EAR 

pendicularly, and upon tapping it lightly with a mallet it inclines 
backward, the tip advancing and shaving the promontorium from its 
attachment. The result of this step of the operation is the exposure 
of the lower half of the first whorl of the cochlea as shown in Fig. 510. 
Indeed, this figure shows the completed Hinsberg operation. 

The after-treatment consists in dressing the wound in all respects 
as you would after a mastoid operation, except the posterior wound 
is left open for four or five days, or until the occurrence of meningitis 
is regarded as improbable. 

THE BOURGUET OPERATION 

Bourguet has devised an instrument (Fig. 511) for the protec- 
tion of the facial nerve during the procedure for the opening of 
the canals. The instrument is provided with a semilunar plate 
3 by 2 mm. in size. The convex border of the plate has a heel or 
toe projecting from it somewhat like the toe of a horseshoe. The 

Fig. 511 




Bourguet's guide and protector. 

heel or toe is inserted into the oval window, while the convex border 
of the plate is directed upward. The body of the plate is thus located 
over the facial canal. When the instrument is thus adjusted the con- 
vexity in the plate is a guide to the junction of the horizontal and 
superior semicircular canals. A small sharp gouge is placed in the 
convexity of the plate, and with a few rotary motions it penetrates 
the bone and exposes the ampullary space beneath the angle. The 
external arm of the horizontal semicircular canal may then be exposed 
to its posterior limit, and, if necessary, the external arm of the superior 
canal may also be exposed by removing its outer wall upward from the 
primary opening at the petrous angle of the two canals (Fig. 513). 

The Bourguet protector and guide is in position, protecting the facial 
ridge and guiding the gouge to the petrous angle at the junction of the 
two canals. 

Technique. — (a) Perform the radical mastoid operation. Remove 
the portion of the zygomatic root and of the roof of the external audi- 
tory meatus, as shown in Plate XXIX to facilitate the use of the 
curette in removing the bony tissue surrounding the canals. 

(b) Proceed to open the petrous angle of the horizontal and perpen- 
dicular canals as described in the Surgery of the Horizontal Semi- 
circular Canal. 



PLATE XXIX 




Anatomical Dissection of the Ear and Surrounding Structures. 



a, a, a, the facial ridge and nerve; b, the horizontal semicircular canal; c, the posterior vertical 
semicircular canal; d, the anterior vertical semicircular canal; e, the oval window; /, the round 
window; g, the promontory; h, the tympanic end of the Eustachian tube; i, the fragment of 
the anterior bony wall of the meatus; j, the internal carotid artery; k, the remaining portion 
of the floor of the meatus (the deeper portion of the floor of the meatus has been removed to 
expose the hypotympanum) ; Z, the internal jugular vein and bulb; m, a section of the bone 
covering the facial nerve; n, the sigmoid portion of the lateral sinus. 



THE BOURGUET OPERATION 969 

(c) Extend the opening upward and backward, thus removing the 
outer walls of the horizontal and superior semicircular canals (Fig. 513). 

(d) With a small curved gouge introduced above and beyond the 
outer limit of the horizontal canal (Fig. 513), remove the superior wall 
of the anterior vertical canal. 

(e) Proceed to complete the opening of the horizontal and anterior 
vertical canals with a small curved gouge and a small thin chisel. The 
major portion of the work should be done with the gouge, a rotary or 
boring motion being used, as the blows of the mallet are liable to frac- 
ture the bone in unexpected directions and afford avenues of infection 
to the meninges. 

Fig. 512 




Schema showing Bourguet's operation upon the horizontal semicircular canal. The facial 
nerve is not actually exposed in the operation. 

(/) Endeavor to open the upper portion of the vestibule, as this 
will insure better results; the semicircular canals open into it. This 
should be done with a small thin chisel curved on the flat. The petrous 
angle of the horizontal and anterior vertical canals, directly above the 
oval window, should first be opened and the gouge used to extend 
the opening downward to the vestibule. The force of the blows of 
the mallet should not be expended upon the facial ridge. That is. the 
gouge should be well above the facial ridge (not resting upon it), as to 



970 



THE EAR 



use the facial ridge as a fulcrum in loosening the chips of bone might 
fracture it and cause facial paralysis (Richards). 

Richards says that this route to the vestibule is safer than that via 
the inner wall of the cavum tympani, as there are no vulnerable points 
to be encountered except the facial ridge, whereas, in removing the 
bridge of bone between the oval and round windows and a portion of the 
promontory, the inner thin wall of the vestibule is more liable to injury, 
especially as the vestibule is shallow at this level and its inner wall 
thin. 



verv 



Fig. 513 




Schema showing the Bourguet and Richards operation upon the semicircular canals, vestibule, 
and cochlea. The semicircular canals are opened, as shown in Fig. 512, with the protector and guide 
in position. The facial nerve is not exposed in the actual operation. 



Then remove the bridge of bone between the oval and round windows 
with a thin sharp gouge, thus exposing the lower space of the vestibule. 
Enlarge the opening, if necessary, to expose a portion of the lower whorl 
of the cochlea (Fig. 513). (This figure also shows the horizontal and 
perpendicular semicircular canals opened.) Gently remove granula- 
tions from the vestibule, and bear in mind that the inner wall of the 
lower portion is thin and easily fractured. 



THE RICHARDS OPERATION 



971 



THE RICHARDS OPERATION 



Fig. 514 



Richards' labyrinth operation is essentially a careful and elaborate 
dissection of the semicircular canals, vestibule, and cochlea. The 
technique employed is admirable, though I doubt its practicability 
in acute suppurative labyrinthitis where the vitality of the patient 
is greatly lowered and the prolonged technique necessary would add 
greatly to the shock which always attends an extensive labyrinth 
operation. 

Technique. — 1. First perform the radical mastoid operation in the 
usual manner. 

2. Having completed the radical mastoid operation, proceed as 
follows to establish as much room as possible for the execution of the 
labyrinth operation: 

(a) Remove the posterior bony 
wall of the external meatus down 
to the Fallopian canal, which 
contains the facial nerve. 

(b) The upper wall of the meatus 
is removed almost to the point of 
exposing the middle cranial fossa. 

(c) The lower wall of the meatus 
is also chiselled away as much as 
possible. These procedures give 
access to the outer (lateral) aspect 
of the labyrinth, greatly facilitating 
the subsequent operation upon it. 

(d) When the external auditory 
meatus is unusually convex at any 
portion the convexity should be 
reduced. 

(e) The tip of the mastoid 
process should be thoroughly removed without injuring the facial nerve 
as it makes its exit from the Fallopian canal. 

(/) The Eustachian orifice should be fully exposed by removing the 
anterior wall of the meatus and the tensor tympani muscle. 

(g) Curette the orifice of the Eustachian tube and apply adrenalin. 

The foregoing steps are taken to give as free access to the labyrinth 
as possible. Operations upon the labyrinth are difficult under the 
most favorable conditions, and as they cause great shock to the patient 
it is important to render the parts as accessible as possible. The 
curettage of the Eustachian tube should be done not only to favor its 
closure but to prevent hemorrhage during the labyrinth operation. 

3. Remove the cancelous bone surrounding the semicircular canals 
(Plate XXIX). This preliminary step will enable the operator to 
accurately and speedily uncover the canals. 

4. The horizontal semicircular canal is then opened at a point above 




Schema showing a cross-section through 
the cochlea from apex to base. The central 
shaded portion (a) is the modiolus. If 
more than the upper apical coil is removed, 
the internal auditory canal (b) at its base 
would be opened, thus exposing the patient 
to the dangers of meningitis. 



972 



THE BAR 



the oval window with a small gouge applied with a rotary boring move- 
ment. This will open it at the ampulla. The canal should then be 
opened, following its course posteriorly to its arch (Fig. 513). Next 
open the outer limb of the superior canal upward to its arch. During 
the opening of the external limb of the horizontal canal great care 
should be exercised to avoid injuring the facial nerve which lies in the 
Fallopian canal immediately below it and above the upper margin of 
the oval window. 

5. The remaining portion of the anterior vertical canal is next opened, 
a small chisel bent at a slight angle being required for this purpose. 

Fig. 515 




Richards' Labyrinth Operation. Showing the complete exposure of the three semicircular canals 
and the upper or suprafacial aspect of the vestibule. The curved probe introduced through the 
oval window extends upward through the opened roof of the vestibule. The tip of the chisel is at 
the ampulla of the external semicircular canal where the initial opening is made in Richards' opera- 
tion. The posterior fossa of the cranium is not exposed in Richards' operation unless positive signs of 
meningitis are present. 

6. The posterior (oblique) canal is then opened, thus completing 
the exposure of all the canals. Only about one-half of the bony walls 
of each canal should be removed, thus leaving small shallow grooves 
marking the position of the canals. When a canal is opened it presents 
a dark granular appearance which might be easily mistaken for clotted 
blood or granulation tissue. 

7. The vestibule should now be opened through the solid angle 
of bone at the confluence of the canals where their ends communicate 
with the vestibule. To open the vestibule, the inner lip of the hori- 
zontal canal must be removed. The chisel must not rest upon the outer 



THE RICHARDS OPERATION 



973 



lip or wall of the canal during this procedure, as the facial nerve lies 
immediately beneath it. Should the outer lip be fractured the facial 
nerve would be injured and facial paralysis follow. Richards urges 
that the outer lip of the canal be preserved intact as a protecting bridge 
to the facial nerve, and that the chisel be held perpendicular to the 
plane of cleavage during the maneuver. The vestibule is exposed as 
fully as possible from this point. It is subsequently more fully exposed 
(during the cochlear operation) by removing the bridge of bone between 
the oval and round windows. This completes the vestibular portion 
of the operation except that portion done in connection with the cochlear 
operation. Occasionally extensive necrosis around the facial nerve 



Fig. 516 




An extensive exposure of the canals and cochlea. 

makes it necessary to remove the bone surrounding it. When this 
becomes necessary, the bone should be shaved off from above down- 
ward parallel with the nerve. When the nerve is thus exposed it lies 
in a bony gutter. It should then be gently lifted from this groove and 
the remaining portion of the bony support removed. In the downward 
course of the nerve, in the posterior wall of the meatus, it usually gives 
off a few filaments which should be cut and not torn. In removing 
the bony tissue supporting the horizontal portion of the nerve (parallel 
with and below the external semicircular canal), which corresponds 
to the upper and inner wall of the tympanic cavity, the chisel should 
be directed from above downward, or from before backward, never from 
behind forward. . . . . • . . 



974 



THE EAR 



8. The vestibule is still further exposed by removing the bridge of 
bone lying between the oval and round windows. This is accom- 
plished by placing the point of a gouge on the bridge and tapping it 
with a mallet. The gouge should be exactly as wide as the bridge of 
bone. The force of the mallet blow should not be great enough to drive 
the gouge against the inner wall of the vestibule, which is not more 
than -gV of an inch in thickness, and forms one of the walls of the internal 
auditory meatus. If this wall is fractured it may become the avenue 

Fig. 517 




Richards' radical operation upon the cochlea and canals. The cupola or apical whorl is removed, 
including the modiolus. This radical exposure of the cochlea should be performed only when menin- 
gitis is already present. 



of meningeal infection. The direction of the gouge should be from 
above, downward and forward. The opening thus made is enlarged 
until the vestibule is fully exposed from this aspect. 

9. The first or lower whorl of the cochlea is then exposed in a for- 
ward direction until the carotid eminence is reached (Fig. 513), a small 
sharp gouge of the width of the cochlear canal being used for the 
purpose. The gouge should be thin and have no shoulder or bevelled 
edge. 

10. The apical whorl is next opened (Fig. 516). The apex of the 



INTRACTABLE AND UNBEARABLE VERTIGO 975 

cochlea forms the most prominent point on the prominence of the inner 
tympanic wall, and is near the Eustachian orifice and the carotid emi- 
nence. The bone is shaved away until the dark outline of the cochlear 
canal is exposed through the thin lamella of bone. The chisel is directed 
from above downward and forward, or, in other words, in the direction 
of the apical whorl of the cochlea. This exposes the proximal half of 
the whorl. 

11. The remaining half of the apical whorl is then exposed by gently 
chiselling away the shell of bone forming the apex down to where the 
first whorl or turn of the cochlea is completed. The apical whorl, as 
shown in Fig. 517, is thus completely removed. To attempt to pene- 
trate more deeply into the middle whorl of the cochlea is to invite the 
occurrence of grave intracranial complications. The internal auditory 
canal, which carries the auditory and vestibular nerves, extends into 
the midst of the cochlea (Fig. 514), and if the modiolus or centre pin 
which supports the whorls is fractured by too deep extension of the 
operation, communication with the cranial cavity is established and 
infection of the meninges becomes probable. 

Only when the meninges are already infected should the whole (2J 
whorls or turns) cochlea be removed. This may be done in an endeavor 
to establish free drainage of the meningeal surface in meningitis of 
labyrinthine origin. The cochlea is already destroyed and meningeal 
infection is established, hence there can be no increase in the danger 
by this procedure; on the contrary, the increased facility for drainage 
from a point at the original site of meningeal infection increases the 
possibility of curing the meningitis. 



INTRACTABLE AND UNBEARABLE VERTIGO 

Mr. Richard Lake has devised an operation upon the vestibule and 
external limb of the horizontal canal for the relief of intractable and 
unbearable vertigo in cases of marked deafness of other origin than 
labyrinth infection. He does not advise the operation in cases with 
useful hearing, but only in those cases in which the hearing is of no 
practical value. Milligan had previously performed a similar though 
less extensive operation for the same purpose. Lake removes the stapes 
and opens the external limb of the horizontal canal and vestibule through 
its roof as in the Hinsberg operation. By this means he destroys the 
membranous vestibular and cochlear apparatuses, and at the same 
time provides free drainage against the possible suppurative inflam- 
mation which might follow the operation. Milligan only opened the 
upper aspect of the external limb of the horizontal canal, and thus 
effectually destroyed the membranous labyrinth as in the Lake opera- 
tion. The advantage of Lake's operation is that freer drainage is 
provided. In both methods of operating the hearing is totally destroyed 
in the operated ear. This is, however, a negligible factor in properly 
selected cases, and does not have force as a contra-indication to the 



976 



THE EAR 



operation. While the operation is not one often required, it is, never- 
theless, of great economic importance to the few who are afflicted by 
this very annoying and distressing condition. 



SURGERY OF BRAIN ABSCESS 

The Surgery of Cerebral Abscess. — Abscess of that portion of the 
cerebrum embraced within the temporosphenoidal lobe may be opened 
through two routes, namely, (a) the tegmen tympani and antri, and (6) the 
squamous portion of the temporal bone. In some cases both routes 
should be employed, especially if the abscess is located high above the 

Fig. 518 




Avenues of approach to brain abscess: a, through the squamous plate to the temporosphenoidal 
lobe; b, through the tegmen tympani to the temporosphenoidal lobe; c, through the mastoid wound to 
the cerebellar fossa; d, through the cranial cortex (one and one-quarter inches posterior to the cavum 
tympani) to the cerebellar fossa. 

tegmen tympani and contains large masses of debris and broken-down 
brain substance which cannot be removed through the perforation in the 
tegmen. In those cases in which the abscess is located near the tegmen 
tympani (roof of the cavum tympani) and in which the contents of the 
abscess are purulent' or fluid, the route through the enlarged perforation 
in the tegmen may prove adequate for drainage. 

Drainage through the Tegmen Tympani. — (a) A preliminary radical 
mastoid operation is first performed, not only to cure the mastoiditis 
and otitis media but to expose the tegmen or roof of the cavum tympani, 
the atrium of the brain infection. 



SURGERY OF BRAIN ABSCESS 



977 



(6) The middle-ear cavity (cavum tympani) is mopped with a cotton- 
wound applicator to free it of pus and blood, and if necessary adrenalin 
chloride solution should be applied to check the hemorrhage. 



Fig. 519 




The incisions for brain abscess: a, b, the primary mastoid incision; c, c, the secondary mastoid 
incision; c, d, an extension of the secondary incision for cerebellar abscess; e, f, the incision for 
abscess of the temporosphenoidal lobe of the cerebrum. 

(c) The tegmen tympani should then be inspected under strong re- 
flected light for oozing pus, and for the dehiscence or perforation result- 
ing from necrosis. A probe may also be used to explore for rough and 
necrosed bone. 

(d) Having located the point from which pus oozes, or where the granu- 
lations protrude from the necrosed area of the tegmen, it should be gently 
curetted to remove the granulations, and to expose the necrotic bone 
and the perforation through it. The opening should be enlarged by 
removing all the necrosed bone (Fig. 518, 6), a dull curette being used 
for the purpose. 

(e) If the abscess is located near the floor of the middle fossa imme- 
diately over the perforation in the tegmen tympani, it may be readily 
drained through this enlarged opening. The dura and brain substance 
may be incised to enlarge the channel of communication between the 
abscess cavity and the cavum tympani (Fig. 518). In one case coming 
under the author's observation the abscess cavity extended into the 

62 



978 



THE EAR 



brain substance for a distance of one and one-half inches, and com- 
municated freely, with the cavum tympani. Large cholesteatomatous 
masses were admixed with the pus, which were readily removed through 
the tegmen opening. In most cases in which the abscess is located as 
high as this, and in which large cholesteatomatous masses are present, 
it is impossible to evacuate the abscess through the tegmen. 

(/) If the abscess is acute, simple drainage and irrigation are usually 
quickly followed by complete recovery. If the abscess is chronic, and 
the walls are lined with necrotic sloughs of brain substance, the healing 
process is much prolonged and requires careful after-treatment. 

Drainage through the Squamous Plate. — The drainage of cerebral 
abscess through the squamous plate of the temporal bone is indicated 
when (a) the opening through the tegmen tympani is not large enough 
to insure adequate drainage; (6) when the abscess is located high in 



Fig. 520 




i z E53iBm Hi 




Circular trephine. 

the brain substance, and only communicates with the perforation in 
the tegmen through a small fistulous tract; and (c) when the associated 
necrotic or cholesteatomatous masses are too large to escape through 
the tegmen opening, or are inaccessible through the tegmen tympani. 

Technique. — (a) It is presumed, if the abscess is of otitic origin, that 
the radical mastoid operation has been performed. The skin incision 
should be extended from the postauricular mastoid incision in a curved 
direction backward, upward, and then forward, as shown in Fig. 519, 
e, f. The flaps are then elevated and retracted with the periosteum. 

(b) A circular plate of bone one-half inch in diameter is then removed 
from the squamous portion of the temporal bone, with a circular trephine 



SURGERY OF BRAIN ABSCESS 



979 



(Fig. 520) . The centre pin of the trephine should be located at a point 
one inch above the posterior wall of the meatus within the square area 
shown in Fig. 521. As the bone is of unequal thickness, one section of 



Fig. 521 




Kronlein's landmarks: b, b, the German horizontal line, or Read's base line, extending from 
the lower margin of the orbit to the occipital protuberance; a, a, the upper horizontal line, extending 
from the supra-orbital margin parallel with the German line; A, e, the anterior vertical line, ex- 
tending upward from the middle of the zygoma at right angles to the German line b, b; d, the middle 
vertical line, passing through the condyle of the inferior maxilla at right angles to the German 
line b, b; c, c, the posterior vertical line, extending from the posterior margin of the mastoid process 
at right angles to the German line b, b; A, f, represents the location of the central fissure of Rolando; 
A,g, represents the fissure of Sylvius; A, B, represents the points for trephining to evacuate blood 
from a ruptured middle meningeal artery. Von Bergmann's area is inclosed within the square 
outlined by the heavy, black lines. Otitic abscess and abscess of the temporal lobe may be drained 
through this area. The upper line of the square represents the area for tapping the lateral ventricle. 
c, B, the sigmoid portion of the lateral sinus; h, the point for entering the antrum; x (in small 
square), area for trephining a cerebellar abscess. 



the circle may be penetrated before the others. The centre pin should 
be set one-eighth of an inch flush with the plane of the teeth of the 
trephine, as this is the average thickness of the squamous plate in this 



THE EAR 

region. The trephine should be removed from time to time, and a small 
probe introduced into all parts of the circular cut to remove the bone 
dust, and to determine if the bone has been cut through at any given 
point. If it has, the trephine should be slightly tilted, so as to cut only at 
the intact portions. When the entire button of bone is severed from its 
attachments, a thin elevator or spatula should be inserted into the 
cut and the button gently lifted from the dura. The button of bone 
should be wrapped in a piece of sterile gauze and placed in a sterile 
or antiseptic solution ready for reinsertion should it be needed — that is, 
if pus is not found. 

(c) Inspect the exposed dura for the following conditions: (1) The 
presence of pus from an associated meningitis. (2) The presence of con- 
gested and infiltrated membranes. (3) The presence of brain pulsation. 
Brain pulsation is usually present when the abscess is large and deeply 
located in the brain substance, or when the abscess is small and super- 
ficial. The absence of pulsation may, therefore, be taken to indicate a 
small deep-seated pus cavity or a large superficial one. Leptomeningitis 
with pachymeningitis may result in the fusion of the meningeal mem- 
branes, and thus obscure the pulsations which would otherwise be present. 

(d) The dura should be incised layer by layer near the centre of the 
opening until its entire thickness is penetrated. It should then be seized 
with forceps, lifted from the underlying structures, and incised the whole 
diameter of the opening. If necessary, a cross-incision may be made to 
overcome the tension. The bloodvessels crossing the field should be cut 
one at a time, pinched with artery forceps, and ligated if necessary, as 
the blood might otherwise penetrate between the membranes and produce 
pressure, or carry infection to other parts. 

(e) The exposed membranes, brain substance, and bone edges should 
be dusted with iodoform powder to protect them from the infected pus 
when the abscess is opened. 

(J) The choice of an instrument for opening the abscess, or for explor- 
ing for it, is a matter of some importance. A hollow needle or cannula has 
commonly been chosen for this purpose. The late Christian Fenger 
preferred a long, slender-bladed scalpel, as it inflicted less damage to the 
brain substance, and at the same time was superior in locating and evacu- 
ating the pus. The needle and cannula are objectionable on account of 
the brain substance entering their lumen when suction is applied, thus 
interfering with the detection and withdrawal of the pus. 

The knife should be passed a distance of one inch into the brain 
substance, then slightly rotated and lifted to open the channel for the 
discharge of the pus. If pus does not appear, it should be introduced a 
half inch deeper and similarly rotated and lifted. The knife should be 
passed to a greater depth than this with great caution, as the lateral 
ventricles (Fig. 522) may be opened and exposed to infection. If pus is 
not found, the knife should be withdrawn and reinserted in another 
plane, and if necessary in several planes, until the abscess is located and 
evacuated. If care is taken to keep the exposed area of the surface of the 
brain and the knife surgically clean, there is but slight danger from this 



SURGERY OF BRAIN ABSCESS 



981 



method of procedure, even when several punctures are made. The parts 
of the brain thus incised are not functionally injured, as the incision is 
clean-cut and the instrument is sterile. 

(g) If the pus is too thick to flow readily through the incision, or the 
necrotic sloughs of brain substance are too large to pass through the 
incised channel, the encephaloscope designed by Whiting should be 
used. It should be introduced over the blade of the knife while it is 
still in the brain, the blade acting as a guide to the abscess. Through the 
opening thus obtained the pus escapes, and the sloughs may be removed 

Fig. 522 




MASTOID CELL5 



EUSTACHIAN TUBE 



A transparent skull showing the relation of the sutures, ventricles, Eustachian tube, tympanic 
cavity, mastoid cells, and lateral sinus of the left side of the head. 



with forceps. When the abscess cavity is emptied its walls may be in- 
spected by the aid of reflected light. If they are necrotic they should be 
curetted until healthy brain substance is exposed. Should such material 
be left in the cavity, the infection and inflammation will be much pro- 
longed. Whiting's encephaloscope affords a means of treatment of 
great advantage that should be utilized whenever the conditions present 
warrant it. 

(h) The abscess cavity should be irrigated with a warm antiseptic 
solution until the return flow is clear. With Whiting's encephaloscope 
or brain speculum the irrigation is a simple matter, as it allows the nozzle 
of the syringe to be introduced and at the same time allows the fluid to 
make its exit into the pus basin. If the encephaloscope is not used, a 
cannula should be introduced the lumen of which is larger than the one 



982 THE EAR 

attached to the syringe, as this allows a return flow of the pus and irriga- 
tion solution. This provision is necessary, because, if the outflow of the 
irrigating solution is blocked, the pressure of the retained fluid may cause 
it to extend beyond the walls of the abscess cavity to other parts of the 
brain. 

(i) The first dressing should consist of a drainage wick of gauze, a 
protective covering of antiseptic powder, and an outer absorbent gauze 
pad. The drainage wick should be within the cavity and in contact 
with the external absorbent gauze pad. The proximal end of the gauze 
wick should be folded over the bony wound and dusted with a mixture 
of iodoform and boric acid (1 to 5), to prevent adhesion between the 
gauze wick and the outer absorbent gauze pad, as it may be neces- 
sary to leave the gauze wick in position for several days; whereas the 
outer gauze pad may, and in many instances should be removed daily. 
In acute cases the walls of the abscess cavity may collapse and heal 
in a day or two. Chronic cases require several days or weeks to heal. 
Macewen recommends that in some acute cases only the outer gauze 
pad be used, and if there is no temperature or pain, that it be left undis- 
turbed for three weeks, the obvious purpose being to avoid the possi- 
bility of infecting the wound by removing the dressing. When, however, 
the discharge is sufficient to soil the outer gauze pad, it should be removed 
daily until healing is completed. 



SURGERY OF CEREBELLAR ABSCESS 

There are three routes available for evacuating abscess of the cere- 
bellum, namely: (a) Through the mastoid wound via the recess at the 
angle of the sigmoid knee (Fig. 518, c), that is, through the recess 
between the inner wall of the antrum and the knee of the sigmoid 
sinus; (b) through the inner wall of the sigmoid sinus when the vessel is 
thrombosed and has been exenterated; (c) through the skull one and 
one-fourth inches posterior to the meatus and below the level of the 
lateral sinus (Fig. 521, x). The lower border of the lateral sinus may 
be determined by an imaginary line passing from the upper margin of 
the zygoma to the upper boundary of the external auditory meatus, 
and thence backward to the occipital protuberance (Fig. 521, b, b). 
Having constructed this line, trephine below it one and one-fourth 
inches posterior to the auditory meatus. This will open the skull below 
the lateral sinus and will afford the most available external route to 
the cerebellar abscess. 

(a) If the abscess is immediately behind the petrous pyramid of the 
temporal bone it may be easily reached through the mastoid wound 
via the recess between the knee of the lateral sinus and the antrum. 

(b) If the lateral sinus is thrombosed (and it is often the source of 
the cerebellar abscess) its walls should be carefully searched for necrotic 
areas, not alone as an avenue of approach to the abscess but as a means 
of tracing the location of the abscess through the fistulous tract leading 



THROMBOSIS OF THE LATERAL SINUS 983 

from the sinus to the abscess cavity. This route may be utilized to 
evacuate the abscess, though the subsequent treatment through this 
route is difficult to carry out on account of the restricted and deep 
situation of the opening in the mastoid wound. This is also true of 
the first (a) route. 

(c) The external route through the skull (Figs. 518, d, and 521, x) 
is generally preferable on account of its accessibility. 

The technique of the operation is otherwise similar to that described 
for cerebral abscess. 



SURGICAL TREATMENT OF SEROUS MENINGITIS 

Serous meningitis has no characteristic symptoms by which it may 
be positively diagnosticated from purulent meningitis. If, however, 
after completing the radical mastoid operation the tegmen tympani or 
antri is opened and serous fluid escapes and the meningeal symptoms 
subside, the diagnosis of serous meningitis may be made (Fig. 518, b, c). 

The surgical treatment consists in doing a decompression operation, 
removing the tegmen tympani or the tegmen antri and allowing the 
serous effusion to escape. The after-treatment consists in the usual 
mastoid dressings. 

Repeated lumbar punctures and the escape of the cerebrospinal 
fluid have been attended with brilliant success in some cases. 

SURGICAL TREATMENT OF EXTRADURAL ABSCESS OR 
PACHYMENINGITIS CIRCUMSCRIPTA 

Circumscribed pachymeningitis, or extradural abscess, located over 
the tegmen tympani or antri in the middle fossa of the skull, may be 
successfully treated in nearly all cases by first performing the radical 
mastoid operation, and then removing the roof of the cavum tympani and 
antri, and evacuating the purulent secretion. An extradural abscess 
is a localized meningitis, the circumference of which is walled off by a 
plastic exudate. 

An early operation upon these cases prevents the spread of the infec- 
tion in the form of a brain abscess and leptomeningitis, which are more 
serious affections. Leptomeningitis is usually fatal, though a few cases 
have recovered under surgical drainage. 



SURGICAL TREATMENT OF THROMBOSIS OF THE 
LATERAL SINUS 

An infective thrombus is more often found in the sigmoid portion of 
the lateral sinus than in any other of the intracranial sinuses. Early 
recognition and surgical treatment is of the greatest advantage to the 
patient, as many cases thus recognized and treated recover. 



984 THE EAR 

Indications for Lateral Sinus Operation. — Since the findings of 
Gruening, Libman, and Oppenheimer, as to the relation of bacteriemia 
(bacteria in the blood) to infective thrombosis of the intracranial 
sinuses, the indications for treatment are rendered possible at a much 
earlier stage than formerly, and with a correspondingly improved 
prognosis. Bacteriemia, usually a streptobaeteriemia, is present in the 
earlier stages of thrombosis of the lateral or other sinuses before the 
distinctive septic symptoms, as a normal or subnormal temperature, 
followed by chills and rigors and a rapid and great rise of temperature 
appear. When, therefore, there is a mastoiditis attended by a constant 
elevation of temperature, and blood-cultures show streptococci present 
in the blood-stream (streptobaeteriemia), the sinus should be operated. 
In such cases, uncomplicated by meningitis, the death rate after opera- 
tion should not be more than 10 per cent. Indeed, it should be less than 
this, as shown by Dr. George L. Tobey in a series of cases in which the 
thrombosis of the sigmoid sinus was operated by ligation only with 
remarkable results. In mastoiditis with a continued high temperature, 
headache, etc., cultures of the blood should always be made, and if 
bacteria are found the sinus should be treated by some form of opera- 
tive interference, as it is made obvious by the blood-cultures that one of 
them, usually the sigmoid, is involved by an infective thrombotic process. 

The earliest indication of sinus thrombosis is, therefore, mastoiditis 
with continued elevation of temperature and bacteriemia. 

When the thrombic process has advanced to the stage of breaking 
down, and the blood-stream is periodically flooded with bacteria and 
septic material, the symptom complex is radically different from what 
it was in the earlier bacteriemic stage. The temperature now fluctuates 
from below or near normal up to 104° to 106° F. daily. The onset 
of the rise in temperature is attended by severe chills and rigors, or in 
infants and young children by convulsions. 

A later and more obvious indication for the surgical treatment of sinus 
thrombosis is mastoiditis with a temperature fluctuating daily from 
near normal to 104° to 106° F., the rise in temperature being ushered 
in by chills and rigors, or by convulsions in infants and young children. 
While the prognosis is not so favorable in this stage of the disease it 
is nevertheless very favorably modified by the proper surgical treat- 
ment, i. e., the exposure and evacuation of the sigmoid sinus and the 
ligation or excision of the internal jugular vein. 

When the thrombus extends backward in the lateral sinus toward 
the torcular it has been recommended that the clot be removed with 
a curette. This procedure is liable to injure the intima of the vessel, 
thus creating favorable conditions for subsequent infective clot forma- 
tions. A better plan is to continue the exposure of the lateral sinus 
toward the torcular, incising the membranous wall of the sinus with 
blunt-pointed scissors as it is exposed. Continue the exposure of the 
sinus to the torcular, if necessary, or until a free flow of blood is 
obtained. This method of procedure is safer and much more certain 
to establish a flow of blood than by curettage. 



THROMBOSIS OF THE LATERAL SINUS 



985 



Technique. — (a) A preliminary mastoid operation is performed. If 
the mastoiditis and otitis are acute, the simple mastoid operation may be 
all that is necessary, the cavum tympani being unmolested ; if, however, 
the mastoiditis and otitis are chronic, and the labyrinth is involved by 
the infective process, the radical mastoid operation should be performed. 
Richards reports 1 1 cases of labyrinthine disease upon which he operated, 
performing more or less extensive exenterations of the labyrinth, of 
which three were affected by thrombosis of the lateral sinus. This, as 
he says, points strongly to the labyrinth as a possible atrium of infection. 



Fig. 523 




Thrombus of the lateral sinus exposed. 

(b) Remove the dense or necrosed bone covering the mastoid aspect 
of the lateral sinus as extensively as possible, thus exposing the mem- 
branous sinus to observation and operation. Determine whether a 
perisinus abscess (extradural abscess of the sinus) is present. Note 
the texture of the membranous sinus, whether velvety, covered with 
granulations at certain points, or necrosed. Palpate it with the ringer to 
determine its resistance, whether doughy, hard, or fluid. Some surgeons 
recommend that the sinus be exposed in every mastoid operation, and 
that a portion of its contents be withdrawn with a hypodermic needle to 



986 THE EAR 

ascertain if pus is present. This is a reprehensible practice, as it is an 
unreliable method of determining the presence of pus, and exposes the 
sinus to the danger of infection. Whiting recommends that the tip of 
the finger be placed as near the jugular bulb as possible and then drawn 
upward toward the knee, noting whether the stripped sinus refills below 
the finger. If it does, the jugular bulb is open. The sinus should then 
be stripped from above downward toward the jugular bulb, and the 
same observation made of the upper portion of the sinus. If it refills, 
the sinus is open above; if it does not, it is closed by a thrombus. Having 
determined to open the membranous sheath of the sinus, see that 
iodoform and boric acid powder (1 to 5) and a strip of iodoform gauze 
(1 x 24 in.) are in readiness in case free hemorrhage occurs. 

(c) Incise the whole length of the exposed portion of the membranous 
sinus (Fig. 523), and if the hemorrhage is free it should be closed by 
turning in the cut edges of the membrane and packing the bony opening 
with the strip of iodoform gauze. A few moments of hemorrhage 
should be allowed, as it may wash out the infective material and lead 
to recovery. 

If the incision is not followed by hemorrhage, the thrombic clot, 
whether it be solid or undergoing disintegration, should be removed 
with a dull curette. The portion of the clot near the jugular bulb should 
be curetted until blood appears at the lower end of the opening. The 
curette should then be passed upward through the knee of the sinus, 
and the clot removed from this part of the sinus. The flow of blood 
from this end of the sinus is evidence that this portion has been cleared 
of the thrombus. Both ends of the sinus should give forth blood. The 
lower or jugular end should be kept closed with the finger while the 
upper end is being curetted, as too much blood might otherwise be lost, 
or the surgeon be impelled to work with undue haste. Having cleared 
the sinus of the clot, it should be filled with the iodoform boric acid 
powder, the edges of the membrane turned in and the bony aperture 
filled with iodoform gauze, and the usual mastoid drainage and absorbent 
dressings applied. 

(d) The dressing may be removed at the end of from twenty-four to 
forty-eight hours, and the gauze removed from the bony aperture of the 
lateral sinus without danger of hemorrhage. 

(e) The after-treatment consists in the usual mastoid dressings here- 
tofore described. 

Should pain, chills, and a rise of temperature occur, the dressing 
should be removed at once and the parts examined to determine the 
conditions which gave rise to the symptoms. If pus is present, endeavor 
to trace it to its source. It will usually be necessary to reopen the sinus 
and extend the curettement, as the sepsis is probably from within the 
sinus caused by fragments of the thrombus that were probably left 
at the time of the primary sinus operation. The sepsis may, however, 
have its origin from a perisinus abscess, and it may become necessary 
to resect the jugular vein and bulb. 



RESECTION OF THE INTERNAL JUGULAR VEIN 987 



RESECTION OF THE INTERNAL JUGULAR VEIN 

The indications for the ligation and resection of the internal jugular 
vein have not been fully established. It is still a question as to when 
the resection increases the danger of spreading the infection, and when 
it prevents spreading the infection from a thrombosed lateral sinus. 
If the internal jugular vein is ligated and resected the anastomotic 
channels, of which there are many, will receive the venous blood cur- 
rent, provided there is a flow of blood through the sinus. If only the 
lower portion of the lateral sinus is closed by an infected thrombus, 
the blood may be forced into the superior petrosal sinus and cause 
thrombosis in it and the cavernous sinus, with which it communicates. 
If the entire sigmoid portion of the sinus is blocked by a thrombus, the 
blood current may be forced backward into the superior longitudinal 
sinus. If the thrombus is limited to the jugular bulb, the blood current 
may be forced into almost any or all of the intracranial sinuses. In 
ligating the internal jugular vein the effect upon the blood current is the 
same as that in jugular bulb thrombus. The question as to when the 
jugular vein should be ligated and removed from the neck resolves itself 
into the consideration of the foregoing facts, and may be stated as 
follows : 

(a) It may be ligated and removed when the entire sigmoid sinus 
and jugular vein are thrombosed and should be obliterated by opera- 
tive procedure. The jugular vein should be removed first, however, to 
obviate the danger of disseminating particles of the thrombus which 
may become detached during the exenteration of the sigmoid sinus. 

(b) The internal jugular vein may be ligated and removed when the 
jugular bulb is thrombosed, the jugular bulb being removed after the 
resection of the vein, if the sigmoid sinus is obliterated at the same 
time, whether it is infected or not. If the sigmoid sinus is left open 
the infective material from the jugular bulb may be forced backward 
through this sinus, and thence through the petrosal to the cavernous 
sinuses. 

(c) The internal jugular vein may be ligated and resected when it is 
thrombosed by extension from a similar condition in the sigmoid sinus 
and jugular bulb. 

(d) The jugular vein should not be ligated and resected when there 
is a flow of blood through the sigmoid sinus. 

(e) In a general way, it may be said that the jugular vein may be 
ligated and resected when the sigmoid sinus is completely blocked with 
an infected thrombus. 

The object of the ligation and resection of the internal jugular vein is 
to prevent the dissemination of the infection to other parts of the body, 
as the lungs, spleen, liver, kidneys, intestines, etc. Statistics show more 
favorable results if this is done when there is complete blockage of the 
sigmoid sinus, and worse results when the sigmoid sinus has a current 
of blood passing through it. 



988 THE EAR 

Technique. — (a) Extend the mastoid incision downward along the 
anterior border of the sternomastoid muscle to the sternal notch (Plate 
XXX and Fig. 476). 

(b) Retract the sternomastoid muscle backward and separate the 
fascia and other structures by blunt dissection until the internal jugular 
vein is exposed. 

(c) The pneumogastric nerve runs between the internal jugular vein 
and the carotid artery and should be respected. 

(d) Ligate the internal jugular vein just above the sternum and just 
below the floor of the external auditory meatus (Plate XXX). 

(e) Ligate all the branches of the vein given off between the upper 
and lower ligations of the iugular vein (Plate XXX). 

(/) Sever the jugular vein just above the lower and just below the 
upper ligatures. Then sever all the branches close to the jugular vein 
and remove the vein from the neck. A gauze pad should be placed under 
the vein before resecting it to protect the tissues from infection. 

(g) The sigmoid sinus is next opened and the thrombus removed 
as described in the preceding section. The danger of disseminating 
the disintegrating thrombus through the jugular vein is largely obviated 
by its removal, though the anastomotic communications are not 
altogether obliterated. 

(h) The sigmoid sinus should be packed and obliterated (Plate XXX), 
and the mastoid wound dressed as previously described, with the excep- 
tion that the lower half of the mastoid incision be left open so that the 
region of the exenterated sigmoid sinus may be subsequently inspected 
and dressed through it. The incision in the neck should be closed 
throughout its entire length, a secondary incision being made one inch 
posterior to the lower angle. This incision should be made to commu- 
nicate with the primary neck wound by tunnelling beneath the skin. A 
spiral tube containing a small wick of gauze should be introduced into the 
secondary incision and extended beneath the skin to the lower portion 
of the primary neck wound, as shown in Fig. 476. The object of the 
secondary incision is to prevent an unsightly scar. As the primary 
wound was occupied by an infected and thrombosed vein, the tissues 
may have become contaminated. Under these circumstances, if the 
tube dressing were introduced into the wound through the primary 
incision, the tissues around the tube dressing would heal slowly and 
cause a retracted and disfiguring scar. The secondary incision, being 
removed from the region of infection, will, after the tube is discontinued, 
heal quickly with little scar and disfigurement. 

(i) The after-treatment, in so far as the wound in the neck is con- 
cerned, consists in the removal of the drainage-tube dressing at the end of 
the third day, or earlier if pain and temperature arise and persist. In 
those cases in which the neck wound is not infected, the tube dressing 
may be dispensed with after the first dressing, a small gauze wick being 
inserted only a little distance into the wound to carry away the excess of 
secretions. The channel occupied by the tube will quickly fill by granu- 
lation, and at the third dressing the gauze wick may be omitted to 



PLATE XXX 




Combined Operation for the Removal of a Thrombosed Sigmoid 
Sinus, Jugular Vein, and Jugular Bulb. 



The sigmoid portion of the lateral sinus has been exenterated and packed with gauze. The 
jugular vein and its branches have been ligated and severed, and the floor of the meatus is being 
removed with a Gigli saw to expose the jugular bulb The facial nerve has been exposed and 
retracted forward with a gauze tape to permit the bone which encloses it to be removed, as it 
is in the operator's pathway to the jugular bulb, though this was not necessary in this particular 
dissection. 



PLATE XXXI 




Anatomy of the Grunert-Panse Exposure of the Jugular Bulb. 

(After Bardeleben. ) 



Grunert removes the tip of the mastoid process and then proceeds toward the jugular foramen 
at the base of the skull. When the jugular foramen is reached he removes the outer and posterior 
portion of the bony ring encircling the vein. As shown in the drawing, the facial nerve lies in the 
way. Panse exposes it, removes it from its canal, displaces it forward, and proceeds to expose the 
jugular bulb. 

1, tympanic cavity; 2, malleus; 3, incus; 4, posterior semicircular canal; 5, saccus endolym- 
phaticus; 6, mastoid emissary vein; 7, lateral sinus; 8, occipital vein; 9, spinal accessory nerve; 
10, facial nerve. 



SURGERY OF THE JUGULAR BULB 



989 



allow the cutaneous edges of the incision to approximate and unite. The 
scar resulting will be slight and the cosmetic effect good. 

The sigmoid and mastoid wounds should be dressed as previously 
described. 

SURGERY OF THE JUGULAR BULB 

The indications for the removal of the jugular bulb are (a) extensive 
necrosis in the region of the bulb; (b) severe systemic infection from the 
disintegrating thrombic clots; and (c) the desire to remove every vestige 
of the foci of infection in order to give the patient the greatest chance 
of recovery. 

Technique. — (a) The mastoid operation is first performed as pre- 
viously described. The simple mastoid operation is performed if the 
case is acute and there are no special indications, as labyrinthine sup- 
puration and necrosis, for opening the cavum tympani. Cerebral abscess 
with the atrium of infection through the tegmen tympani, and sigmoid 
sinus thrombosis with the atrium of infection through the labyrinth, 
etc., necessitates the performance of the radical mastoid operation. 



Fig. 524 



Fig. 525 





The first step in the Passow-Trautmann 
plastic operation for the closure of a persist- 
ent retro-auricular opening. 



The first and second steps in the Mosetig- 
Moorhof plastic operation. 



(b) The internal jugular vein is next resected as described in the 
preceding section (Plate XXX). 

(c) The sigmoid sinus is exposed, exenterated, and packed with 
gauze (Plate XXX). 

(d) The floor of the external auditory meatus is removed, as it is 
in the pathway to the bulb (Plate XXX* and XXXI). 



990 



THE EAR 



(e) The facial nerve may be exposed, as recommended by Panse, 
when it lies in the pathway to the bulb. The nerve should be lifted 



Fig. 526 



Fig. 527 





The third step in the Mosetig-Moorhof plastic 
operation for the closure of a persistent retro- 
auricular opening. 



The fourth step in the Mosetig-Moorhof 
plastic operation for the closure of a per- 
sistent retro-auricular opening. 



Fig. 528 



Fig. 529 




The second step in the Passow-Trautmann 
plastic operation for the closure of a persist- 
ent retro-auricular opening. The sutures a b 
and c d are to be tied to the opposite sutures 
to bring the periosteum together. 



The third step of the Passow-Trautmann plast; 
operation. Closing the skin. 



PLATE XXXII 




Exposure of the Jugular Bulb Completed., the Sigmoid Sinus 
Exenterated and Packed with Gauze and the Facial Nerve Lifted 
from its Canal and Retracted Anteriorly. The facial ridge is 
usually located more anteriorly over the jugular bulb than shown 
in the drawing. 



SURGERY OF THE JUGULAR BULB 991 

from its exposed canal, a strip of gauze passed around it, with which 
it is retracted anteriorly, as shown in Plates XXX and XXXI. 

(/) The styloid process, together with the lower portion of the bone 
which previously supported the facial nerve, and that portion of the 
mastoid tip which obstructs the path of the bulb, should be removed 
with a chisel, bone forceps, or a Gigli saw, as shown in Plate XXX. The 
saw should be placed in front of the fragment of the floor of the meatus, 
the anterior wall having been previously removed. One end should be 
passed backward beneath the tip of the mastoid process, the sterno- 
mastoid muscle being partially severed (Plate XXX), and the other 
backward and over it, and the bone, including the styloid attach- 
ment and the anterior portion of the mastoid tip, sawed through (Plates 
XXX and XXXI). The remaining portion of the bone, especially 
that lying beneath the floor of the meatus, may be removed with 
bone forceps. 

(g) If the transverse process of the atlas projects outward into the 
field of operation, it should be removed, care being exercised to avoid 
injuring the vertebral artery (Bardeleben). 

(h) The outer portion of the thin bone encircling the jugular bulb 
should be removed with bone forceps. 

(i) The jugular bulb, being exposed to surgical interference, should 
be examined, and its condition noted for scientific purposes. As the 
sigmoid sinus above and the internal jugular vein below have already 
been obliterated and removed, there is no added danger in removing the 
bulb which forms the connecting link between them (Plate XXXII). 

(j) The jugular bulb should be removed from the jugular fossa with a 
curette. 

(k) The primary dressing should consist of a gauze wick, the distal 
end of which is inserted into the jugular fossa, and the proximal end in 
contact with the external absorbent dressing. The mastoid, sigmoid 
sinus, and neck wounds should also be drained by spiral tubes with a 
small gauze wick in each. 

(/) The after-treatment consists in applying suitable internal drainage 
and external absorbent dressings until all suppuration ceases and the 
cavities have healed. The mastoid wound should heal by granulation, 
finally becoming covered with epidermis. Should exuberant granula- 
tions form, they should be reduced with caustic applications or with 
the electric cautery, though they will disappear in a few days if Emil 
Beck's bismuth paste (bismuth subnitrate, 1 part; vaseline, 2 parts) is 
used to fill the mastoid wound. The paste should be used daily and 
strands of catgut introduced to promote drainage. Should the mastoid 
bony surface fail to heal within from four to ten weeks, it should be 
freely exposed (the postauricular wound is left open at the time of the 
primary operation), curetted, the hemorrhage checked, and Thiersch 
grafts applied as previously described. 



992 THE EAR 



CLOSURE OF POSTAURICULAR FISTULA 

The Mosetig-Moorhof Method.— This method is adapted to the 
closure of small openings and is performed as follows: (a) The edges of 
the fistulous openings are freshened; (b) a skin flap corresponding in 
size with the opening is made below it, a pedicled attachment being 
left at the upper portion of the flap; (c) the flap is then turned upward 
and placed in the fistulous opening with the skin surface inward; (d) 
it is then fixed in this position by four sutures; (e) finally, the freshened 
edges of the fistulous openings are brought together over the raw surface 
of the skin flap, thus forming an epithelial lining on the inside as well 
as on the outside of the fistulous opening (Figs. 525, 526, 527). 

Passow-Trautmaim Method. — (a) Make a circular incision about one- 
eighth of an inch or more (Trautmann) from the edge of the fistulous 
opening and separate the periosteum and skin; (b) unite the everted 
margins of the periosteum thus loosened with absorbable catgut sutures; 
(c) loosen the skin external to the incision and unite the edges over the 
first periosteal flaps with sutures (Figs. 524, 528, 529). 



CHAPTER LIII 



FACIAL PARALYSIS 



The Plastic Surgery of the Facial and Hypoglossal Nerves.— The 

facial nerve is subject to the same diseases peculiar to other peripheral 
nerves, the most frequent affection being paresis or paralysis. 

Paralysis is characterized by facial deformity, due to the immobility 
of the muscles supplied by the facial nerve. The manifestations are 



Fig. 530 




Facial paralysis of otitic origin. The patient is attempting to close both eyes and to draw 
the mouth on both sides; the right facial nerve being paralyzed, she is unable to close the 
right eye or to contract the right angle of the mouth. 



inability to raise the eyebrow, the skin of the forehead, lip, and cheek, 
and to completely close the eye. The attempt to distend the buccal 
cavity is attended by the escape of air through the paralyzed side of the 
mouth. There is also inability to pucker the lips in whistling, because 
the angle of the mouth droops; this causes the patient a certain embar- 
rassment in speech (Fig. 530). 

Etiology. — 1. Exposure to cold and wet, followed by neuritis and 
perineuritis of the facial nerve. 

63 (993) 



994 THE EAR 



2. A neuritis due to toxemia, syphilis, rheumatism, diabetes, gout, 
leukemia, diphtheria, and other infectious diseases. 

3. Tumors affecting any part of the course of the facial nerve, as intra- 
cranial, intra-osseous, and external neoplasms. 

4. Traumatism, one of the most frequent causes of facial paralysis, 
and one which concerns the otologist. The facial paralysis may arise 
during suppuration of the middle and internal ear, especially chronic sup- 
puration, or suppuration persisting after operative procedures for its cure. 

Facial paralysis may also result from packing the mastoid wound too 
tightly after a mastoid operation. It is known to have been caused 
by the very means devised for the protection of the facial nerve during 
an operation, namely, Stacke's protector in the hands of an inexperienced 
assistant, who presses it too firmly against the facial canal or twists it 
while it is in the aditus ad antrum. 

Curettage of the middle ear for granulations, where the facial nerve is 
not covered by bone, may injure the nerve and cause paralysis. 

The vigorous cauterization of granulations in the middle ear with 
chromic or other caustic acids may also produce facial paralysis. One 
such case came under the author's observation. 

Treatment. — The treatment is divided into: 

1. Medical (local and expectant). 

2. Surgical. 

Paralysis of toxic origin, following exposure to cold or infectious 
diseases, is usually slight, recovery occurring in from one to six months 
by the natural process of repair. The usual treatment in such cases 
is elimination of the toxins by catharsis, the administration of strych- 
nine and other tonics, facial massage, and electricity. These procedures 
are used principally to keep up the muscular tonicity while the nerve 
is regaining its normal function. Paralysis after a mastoid operation 
from too firm packing, or violent reaction, usually subsides within a 
short time after the cause is removed. "When a tumor is pressing upon 
the facial nerve, or the nerve is injured in the removal of the tumor, 
the paralysis frequently disappears soon after the completion of the 
operation. 

In all other conditions causing facial paralysis, wherein the continuity 
of structure of the nerve has been destroyed for a greater distance than 
the process of repair will bridge over, a surgical operation is required 
to effect a cure. 

In order to understand the surgery of the facial nerve it is necessary 
to have a clear conception of its anatomy and physiology. 

The facial nerve arises from a large group of cells situated in the 
upper portion of the medulla oblongata near the junction of the medulla 
and the pons. 

From this nucleus it passes up to the fourth ventricle, forming a 
knee, to the nucleus of the sixth nerve, and comes out at the junction of 
the pons and medulla in connection with the sixth nerve. The fibers 
of the facial lie on the inner side of this composite nerve. From this 
point the nerve passes through the internal auditory meatus, through the 






THE SURGERY OF THE FACIAL NERVE 995 

Fallopian canal, beneath the posterior and lower border of the annulus 
tyinpanieus, through the anterior border of the mastoid process, and 
then emerges from the stylomastoid foramen. From this point it passes 
forward into the substance of the parotid gland, within which it divides 
into three great branches, known as the pes anserinus (goose foot). One 
branch goes to the muscles of the forehead, the eyelid, and the upper 
portion of the malar zygomatic region. The second passes across the 
face, supplying the angle of the nose and the muscles that raise the upper 
lip. Th£ third supplies the muscles at the angle of the mouth, the lower 
lip, the platysma, and the stylopharyngeus muscle. 

At the exit of the nerve from the stylomastoid foramen one branch, the 
auricularis posterioris profunda, is given off, and goes to the muscles of 
the neck. The interosseous portion of the facial nerve gives off a num- 
ber of small branches communicating with other nerves, as the fifth 
and the glossopharyngeal. 

The function of the nerve is to supply the muscles of expression, as 
mentioned above, and it is, therefore, a motor nerve. However, a 
certain amount of sensitive fibers are contained within it, due to its 
gross association with the other intracranial nerves. 



THE SURGERY OF THE FACIAL NERVE 

The operative procedures for the cure of facial paralysis are: 

1. Suture of the severed ends of the facial nerve. 

2. Plastic operations. 

(a) The union of the facial and hypoglossal nerves. 

(b) The union of the facial and spinal accessory nerves. 

(c) The union of the facial and the glossopharyngeal nerves. 
The first procedure, that is, the suturing of the accidentally severed 

ends of the facial nerve, seems to be unnecessary, because if only moder- 
ate loss of substance between the two ends exists, the proximal ends of the 
nerve will regenerate and unite with the distal end without suturing. 

In the plastic operations, the union between either the facial and spinal 
accessory (b) or the glossopharyngeal (c) gives rise to so many untoward 
symptoms following the procedures that they have been practically 
abandoned in favor of the union of the facial and hypoglossal nerves (a). 

The Methods of Anastomosing the Facial and Hypoglossal 
Nerves.— 

1. End to end. 

2. End to side. 

3. Side to side. 

The easiest method is the end-to-end operation, and it is the most 
productive of success, but it necessitates paralysis of the muscles of 
the tongue. The end-to-side operation is to be preferred in all cases, 
as paralysis of the tongue is avoided. The side-to-side procedure has 
only been performed once, with a poor result. 



996 THE EAR 

Plastic Surgery of the Facial and Hypoglossal Nerves; Anasto- 
mosis of the Facial and Hopoglossal Nerves. — Technique. — (a) Gen- 
eral anesthesia, the patient having been prepared as for any other major 
operation. 

(b) An incision of the skin should be made, beginning at the tip of the 
mastoid process, near the lobe of the auricle, and extending downward 
and forward along the anterior border of the sternomastoid muscle to 
the level of the cricoid cartilage of the larynx. 

(c) It should then be carried through the superficial fascia and the 
piatysma muscle, thus exposing the sternomastoid muscle. The external 
jugular vein is usually sacrificed in this procedure, the severed ends 
being tied. 

(d) The anterior border of the sternomastoid muscle and the internal 
jugular vein should be located, and retracted posteriorly, to expose the 
hypoglossal nerve, as shown in Plate XXXIII. The posterior belly 
of the digastric muscle is located more anteriorly and superiorly, as it 
extends from the mastoid tip to its pulley. 

(e) The dimensions of the parotid gland, which is situated on the pos- 
terior border of the ramus of the inferior maxilla, should be determined, 
as the facial nerve divides into three branches within its substance. 
Having located the boundaries of the parotid gland, trace the facial nerve 
to it. The nerve may then be traced backward and upward to its exit 
from the stylomastoid foramen. 

{f) The hypoglossal nerve should then be isolated from the tissues 
covering it. It crosses the external carotid artery just below the point 
where the occipital artery is given off. The nerve should be exposed by 
blunt dissection as far posteriorly as possible, to free it from the tissues. 
This allows the hypoglossal nerve to be brought toward the stump of 
the divided facial, with which it is to be anastomosed. 

(g) The facial nerve should then be drawn from the Fallopian canal 
as far as possible, and severed at the stylomastoid foramen. If it is not 
thus drawn from the canal it will be too short to allow the anastomosis 
of the nerves. 

J. C. Beck has devised a forceps for seizing the facial nerve as it comes 
from the styloid foramen. With this instrument it may be withdrawn 
a half-inch from the canal, which gives sufficient length for union with 
the hypoglossal nerve. 

Having severed the facial nerve, the sheath covering its proximal stump 
should be removed with scissors to expose its axis cylinders (Fig. 531). 

(h) Make an incision one-eighth inch long in the sheath of the hypo- 
glossal nerve, in as close proximitv to the stump of the facial nerve as 
possible (Plate XXXIII). 

(i) The nerve fibers should then be separated with fine-pointed dis- 
secting forceps, so that when the bared axis cylinders of the facial stump 
are inserted into the hypoglossal incision they will be in direct contact 
with those of the hypoglossal nerve. 

(j) A fine silk thread with a small round needle on each end should 
then be passed through the sheath of the facial nerve from without 



PLATE XXXIII 




The Anastomosis of the Facial with the Hypoglossal Nerve. 



a, the parotid gland; b, the stump of the facial and the facial anastomosed with (g) the 
hypoglossal nerve; c, the posterior belly of the digastric muscle; d, the external jugular 
vein; e, the sternomastoid muscle retracted to expose the hypoglossal nerve: /. the 
stylohyoid muscle; g, the hypoglossal nerve; m, the mastoid process. 



THE SURGERY OF THE FACIAL NERVE 



997 



inward, and each needle passed through the sheath of the hypoglossal 
nerve from within the incision outward. The same procedure is then 
carried out on the opposite side of the facial nerve, as shown in Fig. 531. 



Fig. 531 




Schema showing the method of suturing the fascia of the facial with the hypoglossal nerve. 
a, b and c, d, double-needled anchor sutures. 

(k) The operator and the first assistant each handle one suture, and 
draw it tight, while the second assistant separates the lips of the incision 



Fig. 532 




b, b, anchor sutures holding the implanted facial nerve in position in the hypoglossal nerve; 
a, a, a loose running suture closing the longitudinal incision in the hypoglossal nerve. 



in the hypoglossal nerve, the third assistant guiding the pointed stump 
of the facial into the hypoglossal incision. 



998 THE EAR 

The anchor sutures (Fig. 531) are then tied and the axis cylinders 
of the two nerves are thus brought into direct contact. 

The stump of the facial nerve should be directed toward the proximal 
end of the hypoglossal nerve so that stimuli from the brain, coming 
through the hypoglossal, will be more readily transmitted to the facial 
nerve and carried to the muscles of facial expression. 

The sutures should be tied with the greatest care. If too great a num- 
ber of the axis-cylinder fibers of the hypoglossal are caught in the suture 
there will be a certain amount of paralysis of the tongue (Fig. 533). 

Fig. 533 







Partial lingual paralysis shown upon protrusion of the tongue, due to the injury of a few of 
the fibers of the hypoglossus nerve at the time of the union of the facial and the hypoglossus nerves. 
a, the area paralyzed. (Dr. J. C. Beck's case.) 

Too great tension of the hypoglossal nerve will also result in lingual 
paralysis, hence the necessity of drawing the facial from the Fallopian 
canal, and dissecting the hypoglossal nerve as far posteriorly as possible, 
to give it greater freedom of displacement toward the stump of the facial 
nerve. 

(/) A secondary continuous suture should then be passed through the 
lips of the hypoglossal incision, as shown in Fig. 532, a, a. This suture 
should not be tied, but drawn tightly. 

(m) The anastomosed nerves should be covered with a piece of cargile 
membrane, and the muscles of the neck replaced in their normal posi- 



THE SURGERY OF THE FACIAL NERVE 

tions. The cargile membrane prevents the formation of scar tissue and 
adhesions, which would greatly interfere with the success of the operation. 

{n) The final step of the operation consists in suturing the superficial 
fascia and skin, drainage being unnecessary, as the operator's field is 
aseptic. 

After-treatment and Observations. — The skin stitches should be removed 
in from five to seven days, and as soon thereafter as possible massage, 
electric and tonic remedies should be instituted. 

The earliest manifestations of the proper union of the nerves is the 
appearance of a certain amount of tonicity in the muscles of the paralyzed 
side of the face. This change is only an indication that anatomical union 
has occurred, and should not be construed as a beginning of functional 
activity. On the contrary, it may be weeks, months, or even a few years 
before functional activity is manifested. 

The first sign of functional activity is a slight contraction of the muscles 
supplied by the lower of the three branches of the pes anserinus, namely, 
the muscles of the lower lip and the angle of the mouth. At a little later 
period, the muscles of the upper lip and the forehead show functional 
activity. 

A still later development is the contraction of the facial muscles simul- 
taneously with the act of deglutition. This gradually increases until the 
contraction on the paralyzed side is greater than on the unaffected side, 
which is very disagreeable to the patient. 

The simultaneous contraction of the facial and hypoglossal muscles 
is very annoying and confusing. The patient soon learns, how r ever, to 
disassociate the movements, and is able to swallow with a constantly 
decreasing degree of facial distortion, until finally the facial muscles 
remain quiet during the acts of deglutition. 

The final and most desirable result is the voluntary contraction of the 
facial muscles independent of the act of swallowing. 

The time required to obtain such a result varies greatly, depending 
upon the amount of muscle degeneration before the operation, the accu- 
rate apposition of the two nerves, and the general condition of the patient. 

The reaction of the muscles supplied by the facial nerve should be 
tested with the electric current in long-standing cases, to determine 
whether they are still active. If contractions are not produced — that is, 
if complete atrophy of the muscle is present — it is useless to operate. 
The contraction of the masseter muscles should not be mistaken for the 
contraction of the facial muscles. One case of fourteen years' standing 
was successfully operated. 



CHAPTER LIV 

NON-SURGICAL DISEASES OF THE LABYRINTH 
HYPEREMIA OF THE LABYRINTH 

Etiology. — The etiology is generally associated with either congestion 
of the middle ear or the contents of the cranial cavity. It is rarely 
primary in the labyrinth. It is usually found in acute suppurative 
otitis media following scarlet fever, diphtheria, and typhoid fever. It 
may also be caused by the other exanthematous fevers, pneumonia, 
encephalitis, mumps, puerperal fever, meningitis, and tumors at the 
base of the brain. Thrombi in the sinuses contiguous to the petrous 
portion of the temporal bone and the internal jugular vein, goitre, 
angioneurotic congestion of the cranial vessels, intracranial affections of 
the trigeminus, diseases of the medulla oblongata, and the internal use 
of quinine, salicylic acid, and amyl nitrite may also cause it (Politzer). 

Symptoms. — The symptoms are tinnitus, slight feeling of fulness in the 
head and ears, nausea, vomiting, spontaneous nystagmus to the affected 
side, and unsteady gait. The nystagmus is due to stimulation of the 
congested vestibular apparatus and is a typical "sign of stimulation 
disharmony." In destruction of the labyrinth the nystagmus is to the 
opposite side, and is a sign of destruction disharmony. The handle 
of the malleus may be injected, and, when present, denotes a general 
hyperemia of the organ of hearing. The face and auricle may in rare 
cases be red. If there is a sense of dazzling whiteness before the eyes, 
the hyperemia is probably of intracranial origin. 

Treatment. — If the hyperemia is secondary to middle-ear inflamma- 
tion special attention should be addressed to that disease, and with 
the subsidence of the middle-ear disease the labyrinthine symptoms 
will disappear. The patient should be put in bed, given laxatives, and 
have leeches applied to the nape of the neck and mastoid process. He 
should lie upon his affected ear, as this will cause him to look to the 
slow component when the eyes are open, and thus relieve the nystagmus 
and giddiness. If there is active inflammation in the middle ear and 
mastoid process the ice-bag or Leiter's coil should be applied to the 
mastoid region for one hour. 

If the disease arises from an intracranial lesion, the treatment should 
be addressed to that condition, the ice-bag applied to the vertex, saline 
cathartics given, and alcoholic beverages and tobacco prohibited. In 
general, the habits should be well regulated, constipation prevented, 
and the beneficial effects of fresh air and sunshine should be taken 
advantage of by the patient. 
( 1000 ) 



ANEMIA OF THE LABYRINTH 1001 



ANEMIA OF THE LABYRINTH 



Etiology. — The etiology is usually a coexisting general anemia. It 
may exist, however, as a local condition due to hemorrhage, the obstruc- 
tion of the internal auditory artery from aneurysm of the basilar artery, 
neoplasms of the dura or brain extending into the internal auditory 
canal, embolism of the internal auditory artery, and atheromatous con- 
striction of the internal auditory artery. 

Symptoms. — In the angioneurotic and posthemorrhagic forms, the 
symptoms closely simulate those of seasickness : there is nausea, vomit- 
ing, severe tinnitus aurium, deafness, facial pallor, and dizziness. All 
these symptoms disappear with the return of the blood to the normal 
state. In the chronic form the tinnitus and deafness are the chief 
symptoms. 

Treatment. — If the labyrinthine anemia is angioneurotic in origin, 
the neurosis should receive appropriate attention; perhaps a long sea 
voyage, residence in the mountains or at the seashore, primitive camp 
life, etc., might be beneficial. If the cause is an excessive hemorrhage, 
transfusions of normal saline solution should be given, or spontaneous 
relief may come after a more or less prolonged period of waiting. If 
it occurs in one who is subject to repeated severe hemorrhages, the 
duration of the ear symptoms is somewhat prolonged, and means to 
prevent the recurrences of the hemorrhages should be carefully con- 
sidered in the treatment. In the angioneurotic type, the internal 
administration of the bromide of soda and the application of the 
galvanic current to the sympathetic nerves of the neck are indicated. 



HEMORRHAGE INTO THE LABYRINTH 

Small hemorrhages into the labyrinth may occur during the course 
of the exanthematous fevers, on account of the increased blood pressure 
and the rapid degenerative changes which sometimes characterize the 
progress of these diseases. The hemorrhages also occur in caisson 
workers and divers, and in prolonged suffocative seizures. Diabetes, 
nephritis, and sudden cessation of menstruation may also furnish the 
cause and atheromatous degeneration of the walls of the arteries pre- 
disposes to labyrinthine hemorrhage. 

More extensive hemorrhages into the labyrinth occur in fractures of 
the skull, involving the petrous portion of the temporal bone; from 
severe contusions of the skull; from extension of carious processes in 
the temporal bone, and from primary and tuberculous meningitis 
(Politzer). 

Course and Termination. — The course and termination of the hem- 
orrhages into the labyrinth are obviously variable, according to their 
severity and origin. The blood clot persists in the labyrinth for a variable 
time, after which they may be absorbed, become organized, or the epi- 



1002 THE EAR 

thelium, connective tissue, nerve elements, etc., involved by the pressure 
may become atrophied and degenerated. Politzer reports a case which 
ended in suppuration. 



MENIERE'S DISEASE 

This condition is characterized by sudden and complete loss of hearing, 
attended with tinnitus, nausea, vomiting, spontaneous nystagmus and 
vertigo, without a previous history of ear disease. It is supposed to be 
due to a hemorrhage into the labyrinth. The patient is usually robust, 
middle aged, and has never previously complained of deafness. At the 
onset of the attack he sometimes falls unconscious to the ground. In a 
case seen by the author, the attack came on at night. Upon attempting 
to rise in the morning he had severe dizziness (indeed, could not walk), 
nausea, vomiting, tinnitus, spontaneous nystagmus, and complete 
deafness. The history of the case showed that two years previously 
the left ear was similarly affected, the hearing remaining almost nil 
in that ear, the right being normal. It is now thirteen years since the 
last attack, and the hearing is unimproved. 

The hearing by bone conduction is lost if the affection is bilateral, 
and when unilateral the sound of the tuning fork, when placed on the 
vertex, is later alized to the unaffected side. 

The course of Meniere's disease varies. The unconsciousness rapidly 
disappears, and the vomiting a little more slowly. The dizziness and 
staggering gait remain for several days. In the author's case the patient 
had a tendency to walk to the right for four or five days (direction of 
the slow component of. the nystagmus), after the apoplectiform attack 
in the right ear, he was dazed, and thought slowly for some weeks. 
His handwriting was not tested. Guye and Politzer report that for 
a time the handwriting is like that of a tremulous old man. The 
unsteady gait may persist for years. Relapses usually occur, although 
there are exceptions to the rule. 

Diagnosis. — The diagnosis of Meniere's disease can only be made with 
certainty when the patient is examined immediately after the seizure. 
If the middle ear, drumhead, and Eustachian tubes are normal and 
the patient gives the clinical picture just described, and there is no 
paralysis of other cranial nerves, a diagnosis of Meniere's disease may 
be made. 

This disease should be differentiated from Meniere's symptom com- 
plex, which is usually due to an intermittent closure of the Eustachian 
tubes. The rarefaction of the air in the tympanic cavity retracts the 
membrana tympani and forces the foot plate of the stapes into the oval 
window, thus increasing the tension of the labyrinthine fluids and giving 
rise to the symptoms of Meniere's disease. An examination of the 
drumheads and Eustachian tubes, however, shows retraction of the one 
and obstruction of the other. After inflation of the tympanic cavity the 
symptoms disappear and only return when the air in the tympanum 






MENIERE'S SYMPTOM COMPLEX 1003 

becomes rarefied. The history of the case shows repeated recurrences 
of deafness and Meniere's symptom complex. 

Prognosis. — The prognosis is unfavorable, little improvement being 
reported in the cases thus far recorded. 

Treatment. — The treatment is directed principally to the re fief of 
the dizziness, nausea, and vomiting. The patient should be placed in 
bed with the head slightly raised, to avoid the necessity of changing 
the position in giving food and medicines, as the movements attending 
these acts increases the disorders present. This precaution should be 
observed for a few days while the symptoms are annoying. Cold com- 
presses to the head, mustard plasters to the nape of the neck and calves 
of the legs, and the administration of purgatives may hasten the disap- 
pearance of the annoying symptoms. The tinnitus is often relieved by 
the administration of quinine and the iodide of potash, or, what is prob- 
' ably preferable, iodonucleoid, in which the iodine is united with nucleinic 
acid, thus rendering it readily digestible and easily and rapidly absorbed, 
without irritating the stomach. If the quinine causes mental excite- 
ment and increased tinnitus, its use should be discontinued (Charcot). 
It should be given in 2 grain to 5 grain doses three times daily for six 
or eight weeks. The iodide of potash (or iodonucleoid) may be given 
for three or four weeks. 

To promote absorption of the blood clot and exudate, pilocarpine, in 
2 per cent, solution, may be injected 4 to 10 drops daily; or it may be 
given internally for the same purpose. Its use should not be begun until 
about the third week, when the acute symptoms have subsided. 



MENIERE'S SYMPTOM COMPLEX 

This condition, while similar in its manifestations in many respects to 
Meniere's disease, should not be confounded with it. Meniere's symp- 
tom complex is characterized by dizziness, staggering gait, nausea, 
tinnitus, and more or less deafness, with a distinct history of previous 
deafness and ear disease. The deafness does not occur suddenly, and is 
not complete, nor are the profound disturbances found in true Meniere's 
disease present. The author once saw a case in consultation, in which 
nearly all the signs of Meniere's disease were present, the exceptions 
being: (a) There was a history of previous deafness and ear disease; (b) 
the deafness did not occur suddenly, nor was it profound; (c) inflation 
of the middle ear through the Eustachian catheter gave immediate and 
complete relief. The case was one of Eustachian catarrh, complicating 
a similar process in the epipharynx. The air in the middle ear became 
gradually rarefied by the absorption of the oxygen by the blood, the 
drumhead was retracted, and pushed the foot plate of the stapes in- 
ward, which compressed the intralabyrinthine fluids, and gave rise to 
the foregoing phenomena. The same phenomena may be due to chronic 
catarrhal adhesive processes. According to Politzer, a great majority of 
the cases are due to a temporary congestion of, or exudation into, the 



1004 THE EAR 

labyrinth arising in the course of middle-ear infections, which bring 
about an irritation of the vestibular and ampullar nerves. 

Dr. Geo. E. Shambaugh recently advanced the theory that the tinnitus 
attending this affection was due to a disturbance of the relation of the 
membrana tectoria to the hair cells of the organ of Corti. He holds 
that the membrana tectoria is the resonator of the perception apparatus, 
whereas, according to Helmholtz, the basilar membrane is the resonator. 
(See Physiology of the Labyrinth.) 

The use of the tuning-forks enables the observer to differentiate be- 
tween cases of middle-ear origin and those of labyrinthine origin. If 
with marked diminution of hearing there is positive Rinne, with hearing 
for low tones preserved, the lesion is in the labyrinth ; if, on the contrary, 
there is a negative Rinne, with loss of hearing for low tones, the lesion 
is in the conduction portion of the temporal bone, i. e., in the middle ear 
and Eustachian tube. If the disease is unilateral, the vibrating tuning- 
fork placed upon the vertex will, if the lesion is in the middle ear or 
Eustachian tube, lateralize toward the affected side; whereas, if it is in 
the labyrinth it will lateralize toward the normal or unaffected side. 

Some cases reported by Urban Pritchard and Richard Lake were of an 
epileptiform type, with a tendency to fall toward the affected side. The 
room seemed to whirl, the face became pale, the eyes dull, the skin 
covered with cold perspiration, and the pulse small and often retarded. 

The course of the symptoms is extremely variable, lasting from a few 
moments to several days or weeks. 



Fig. 534 




Siegle's otoscope. 

Treatment. — In those cases due to hyperemia of and exudation into 
the labyrinth, the same treatment recommended under hyperemia of the 
labyrinth is of value. If the lesion is in the Eustachian tube or middle 
ear the remedies suited to the condition present should be used. Quinine 
is perhaps more valuable for the relief of the tinnitus than it is in 
Meniere's disease. Pneumomassage, especially rarefaction (suction) of 
the air in the external meatus, in either the middle ear or labyrinthine 
type, is beneficial in many cases. Its rationale in the middle-ear type is in 
the outward movement of the drumhead, which relieves the pressure upon 
the foot plate of the stapes, and in the labyrinthine type the lessened 
pressure in the middle ear relieves the labyrinthine congestion. Rare- 



ARTERIOSCLEROSIS OF THE LABYRINTH 1005 

faction can be practised by means of a rubber tube with a metal tip, the 
patient supplying the suction power with his mouth at the other end of 
the tube, or Delstanche's rarefacteur or Siegle's otoscope (Fig. 534) may 
be used with equally good results. 



ARTERIOSCLEROSIS OF THE LABYRINTH 

According to J. J. Kyle, arteriosclerosis of the labyrinth may be local, 
or a part of a general sclerosis of the arterial and cellular structures of 
the body. 

Etiology. — "The cause of arteriosclerosis of the labyrinth is the same 
as in any other part of the body, and may be syphilis, laborious occupa- 
tion, alcoholism, lead poisoning, infectious fevers, auto-intoxication, 
vasomotor disease, and heredity." 

Syphilis is probably the most important factor in the etiology of the 
disease in middle life. 

The disease may be unilateral or bilateral, and is observed early 
or late in life. 

Pathology. — "The affection probably begins as a structural change 
in the vasovasorum and is fibrous in character. The labyrinthine 
artery is the single artery of the labyrinth, and as soon as the nutrition 
of its wall is disturbed connective- tissue degeneration takes place in the 
media. Fatty degeneration soon follows in the intima with the deposit 
of calcareous salts. The vessels may sometimes become narrowed or 
obliterated. 

"As soon as the nutrition of the basilar membrane and organ of Corti 
is partially or completely cut off, there is atrophy of the sensory audi- 
tory cells and connective-tissue proliferation of all the structures. The 
same change may be observed in the nerve endings of the vestibule and 
semicircular canals. 

"The change in the brain structures varies according to the amount 
of nutrition carried to the parts. In endarteritis obliterans of the vessels 
supplying the centre of hearing and equilibration, there is, on account of 
the slow change in the arterial walls, degeneration and atrophy of the 
brain cells." 

Symptoms. — "The symptoms of arteriosclerosis are both general and 
local. The general symptoms are increased arterial tension, increased 
tortuosity and prominence of the arteries of the temple, hypertrophy of 
the heart, and, if the last is present, there is generally a lowered vitality 
of the individual, a feeling of age, and tiring, as from overwork, followed 
by an appearance of aging. Analysis of the urine usually shows increase 
of the urates and long, thin hyaline casts, undergoing granular degen- 
eration. 

"The ear symptoms are unilateral or bilateral tinnitus, slight and 
progressive deafness, impairment of air and bone conduction, in some 
cases dizziness early in the disease, and in the later stages hallucinations 
of hearing may be present. The ear symptoms necessarily vary accord- 
ing to the extent of the sclerosis." 



1006 THE EAR 

Diagnosis. — "The above symptoms, both general and local, should 
always direct the physician's attention to the possibility of arteriosclerosis. 
The early diagnostic symptoms are tinnitus, vertigo, nutritive change 
in the membrana tympani, and slight unilateral or bilateral deafness. 
If the general symptoms, as enumerated above, are present the diag- 
nosis is usually complete. 

"The location of the lesion, whether in the nuclear or labyrinthine 
endings of the nerve, may, according to Gradenigo, be shown by the 
tuning-forks. A diminution in bone conduction and the loss of high 
tones is indicative of labyrinthine deafness. In central deafness there 
is a pronounced loss of perception for both high and 1ow t tones. 

"The disease should not be confounded with Meniere's disease, 
hyperemia of the auditory nerve, hysterical deafness, hemorrhagic 
extravasation in the labyrinth from a fall or blow upon the head, or 
nerve deafness from toxic absorption." 

Prognosis. — "The prognosis is usually poor so far as the restoration 
of hearing or complete cure of the tinnitus is concerned. Under general 
treatment the symptoms may frequently be relieved and often brought 
to a standstill." 

Treatment. — "The treatment of arteriosclerosis of the ear is both 
general and local, depending somewhat upon the exciting cause. Cases 
with hereditary predisposing factors do not respond to treatment as 
well as those due to syphilis or acquired diseases. However, in both 
conditions, the iodide of potassium in from 2 to 5 grain doses, four or 
five times daily for long periods of time, is indicated." 



LEUKEMIC DEAFNESS 

Leukemic deafness is characterized by either sudden and complete 
deafness and Meniere's symptoms, or by moderate • deaf ness which 
speedily grows worse, until within a few weeks or months it becomes 
complete. In acute leukemia the deafness and other ear symptoms 
occur in the early stage of the disease; whereas in chronic leukemia 
they usually appear in the later stages. The pathological changes 
consist of accumulations of lymphocytes, and hemorrhages into the 
labyrinth, followed by a reactionary inflammation of the endosteum 
and membranous labyrinth, which finally results in connective-tissue 
obliteration and partial ossification of the labyrinth (Politzer). The 
prognosis is obviously unfavorable. 



OTITIS INTERNA PAROTITICA 

(Diffuse Manifest Suppurative Labyrinthitis) 

Mumps being an infectious disease, and the site of infection being 
anatomically in close proximity to the labyrinth, the infection may be 



SYPHILIS OF THE INTERNAL EAR 1007 

carried to it by metastasis, or it may be carried through the Glaserian 
fissure. Symptoms and treatment have been thoroughly discussed in 
the chapter on Diffuse Manifest Suppurative Labyrinthitis, and hence 
will not be considered here. 



SYPHILIS OF THE INTERNAL EAR; SYPHILITIC OTITIS INTERNA 

Syphilitic diseases of the labyrinth usually appear at the end of the 
secondary or at the beginning of the tertiary stage. Politzer, however, 
reports a case in which there was labyrinthine involvement seven days 
after the initial lesion. It may involve the labyrinth in common with 
the middle ear, or as one of the signs of a general infection, or it may be 
limited to the internal ear. 

Pathology. — The pathology is but little known, as only a few cases 
have been carefully studied. From the examinations made it appears 
that there is present thickening of the periosteum of the vestibule (Toyn- 
bee, Moos), displacement and fixation of the foot plate of the stapes ? 
small-cell infiltrations and hyperplasia of the connective tissue between 
the membranous and bony labyrinth; also infiltration of Corti's organ, 
of the ampulla?, and of the membranous semicircular canals (Moos). 
The canals and spaces of the labyrinth have also been found filled with 
new bony tissue. The acoustic nerve may or may not be affected. 
Adhesive bands, hornification, atrophy and destruction of the ganglionic 
cells, and syphilitic endarteritis (Baratoux and Virchner) have been 
reported. 

Symptoms. — The symptoms are those of labyrinthine involvement 
in general, namely, loss of hearing by bone conduction, and for high 
tones and spontaneous nystagmus in the early acute stage when the 
vestibular apparatus is destroyed. If the affection is unilateral (rare), 
the Weber experiment will show lateralization of hearing to the normal 
side, and Rinne will be decidedly plus upon the affected side. The 
symptoms may appear suddenly, with tinnitus, deafness, dizziness, 
nystagmus, and staggering gait. The nystagmus is spontaneous during 
the acute stage, whereas in the latent period it. only appears upon the 
use of the various tests if the destruction is partial or is negative when 
the destruction is complete. (See Functional Tests of the Vestibular 
Apparatus.) The deafness may become complete and permanent, 
the tinnitus increasing at the same time. The staggering gait and 
dizziness may disappear after a few days or weeks. Diplacusis and pain 
in the ear may be present, the pain being due to a periosteal growth in 
the labyrinth. 1 

Objectively, the signs of syphilis of the internal ear may be wanting. 
It is only when the middle ear, or Eustachian tube, and labyrinth are 
simultaneously involved that objective signs are found. There may 
then be the usual appearance of a catarrhal otitis media, or the charac- 
teristic swelling of the mucosa of the Eustachian tube. Syphilitic 
ozena of the nose and epipharynx may also be present. 

1 Moss and Stein brugge, Zeits. f. Ohrenh., vol. xiv. 



1008 THE EAR 

Course. — In most cases the deafness develops gradually for some 
weeks or months, remains stationary, and then, after a variable interval, 
suddenly becomes much worse. More rarely the deafness comes on 
suddenly. Slight exciting causes may bring on a rapid increase in the 
deafness. Concussions on the head, blows, etc., have been known to 
do the same thing. In rare cases improvement and recovery take place, 
and hearing by bone conduction gradually returns. 

Diagnosis. — The differential diagnosis between syphilis, otosclerosis, 
and other forms of labyrinthine disease is not always easy, except when 
there are evidences of the secondary or tertiary manifestations of 
syphilis. Unfortunately, in many cases no such obvious signs are 
present. Politzer observes that " those forms of severe or total deafness 
which usually develop in both ears during childhood must be regarded 
as syphilitic affections of the labyrinth. Such cases were formerly 
supposed to be due to scrofula." The diagnosis of hereditary syphilis 
is aided by the presence of middle-ear catarrh, purulent otitis media, 
adhesive processes of the middle ear, and chronic interstitial keratitis 
(opacity of the cornea). When the syphilitic infection involves the 
middle ear, and the membrana tympani is perforated and discharges 
a purulent secretion, the disease is often mistakenly diagnosed as 
suppurative otitis media. If it persist in severe form syphilitic infection 
should be suspected and a Wassennann test made. Indeed, the 
Wassermann test should be made in all suspected cases. 

Prognosis. — Recent cases offer a favorable prognosis, while older 
ones are quite unfavorable. The degree of deafness is not a safe guide 
in giving a prognosis, as totally deaf cases have been known to recover, 
while others, with mild deafness, have remained unimproved. General 
debilitating diseases render the prognosis more grave. The hereditary 
type, with opacity of the cornea, is unfavorable. 

Treatment. — Mercurial injections, with the internal administration 
of iodonucleoid or iodide of potassium, are indicated. Pilocarpine 
injections, 4 to 12 drops daily, of a 2 per cent, solution, beginning with 
4 drops and increasing to 12 drops, sometimes influences the case favor- 
ably (Politzer, Bacon, Gradenigo). The injection of solutions of the 
iodide of potassium into the middle ear through the Eustachian catheter, 
as recommended by Politzer, is not to be generally favored. The tech- 
nique of such a procedure gives rise to the extreme liability of carrying 
infection into the middle ear. Under strict antiseptic precautions and 
a knowledge of the extremely small size of the tympanic cavity, and the 
technique of the whole procedure, the danger of infection disappears; 
and it is possible, though in the author's opinion not probable, that the 
injection of a solution of the iodide of potassium will affect the course 
of the disease favorably. The injections of iodoform, iodine vasogen, 
mercurial ointments etc., are more rational methods of treatment. It 
should not be forgotten, however, that the disease is essentially a 
systemic one. 

Salvarsan in Syphilis of the Auditory Apparatus.— The use of salvarsan 
in syphilitic infection of either the sound conduction or the sound 
perception apparatus has, since Ehrlich introduced it, received both 



SYPHILIS OF THE INTERNAL EAR 1009 

laudatory and condemnatory criticism. It has been claimed that its 
use was the cause of neuritis of the auditory and other cranial nerves, 
and that deafness was often due to it. Indeed, the earlier results 
following its use seemed to warrant such a conclusion. A careful 
analysis of the cases in which the auditory nerve was involved has, 
however, shown rather conclusively that the neuritis and consequent 
deafness were in all probability due to the faulty preparation of the 
salvarsan and to the use of insufficiently large doses. At least since 
the salvarsan has been prepared under strict antiseptic precautions, and 
has been given in larger doses, the occurrence of neuritis of the audi- 
tory nerve, and the deafness resulting therefrom, have been markedly 
diminished. Nevertheless the question should be submitted to further 
observation and discussion before an ultimate estimate of the position 
salvarsan should occupy in the treatment of syphilis and non-syphilitic 
disease of the ear. In the meantime it is undoubtedly true that sal- 
varsan is a most valuable therapeutic agent in the treatment of syphilis 
of the auditory apparatus. I will endeavor, therefore, in the following 
paragraphs of this section to give a summary of the facts of clinical 
significance, especially as they relate to the preparation and dosage of 
salvarsan. 

Preparatory to the discussion of the use of the salvarsan I will 
briefly review some of the statistical data and opinions presented by 
various writers upon this subject. 

J. Bernario has, perhaps, made the largest collection of cases of 
syphilis treated by salvarsan, and has deduced from his critique of 
the aggregation of cases certain facts of great interest to otologists. 
In his analysis of 14,000 cases of syphilis treated by salvarsan (606, 
arsenobenzol) he has formulated the following facts in relation to 
lesions of the cranial nerves following its administration : 

1. Cranial nerve lesion occurred in 126 cases, 118 in the early and 
secondary stages of syphilis, and 8 in the tertiary stage. In other 
words, one cranial nerve lesion was present in every 111 cases of the 
14,000 treated by salvarsan. 

2. Auditory nerve lesion was found in 62 cases, or once in every 226 
cases. 

3. Of the 62 auditory nerve lesions 11 were accompanied by the 
involvement of other cranial nerves, especially the optic nerve. In 
51 cases the auditory nerve alone was affected, and of these the cochlear 
branch alone in 29 cases, the vestibular branch alone in 5 cases, and 
both branches in 17 cases. 

4. Of the 126 cases of cranial nerve involvement the lesion occurred 
in 96 per cent, of the cases within the first four months after the injec- 
tions of salvarsan. Of the 96 per cent., 40 per cent, occurred during 
the second month. 

As the nerve lesions followed the use of the salvarsan within a rela- 
tively short time it was at first throught they were due to the irritation 
of the arsenic in the salvarsan. Subsequent observations appear to 
have shown this hypothesis to have been wrong. Ehrlich explained 



1010 THE EAR 

the occurrence of cranial nerve lesions as being due to insufficient 
dosage and the improper preparation of the salvarsan. He claimed 
that the spirochsetse within the sheath of the auditory and other cranial 
nerves were protected by their dense fibrous envelopes, thus preserving 
the integrity of the specific germs, whereas they were destroyed in 
other parts of the body. After the lapse of from two to four months 
the spirochsetse became actively destructive to the nerves protecting 
them, and deafness, blindness, etc., followed. While this theory does 
not adequately explain the clinical phenomena, it at least has the 
merit of explaining some of them. His suggestion that larger doses of 
salvarsan were required to destroy the spirochsetse within the sheaths 
of the cranial nerves than elsewhere in the body has been sustained 
by subsequent experience. His theory seems to convey the idea that 
insufficient dosage of salvarsan has a tendency to augment the virility 
of the spirochsetse protected in the sheaths of the cranial nerves in a 
percentage of cases, whereas this is probably not true. 

Alexander, on the other hand, believes that the cranial nerve lesions 
are due to the action of the salvarsan and not to the spirochsetse, as 
claimed by Ehrlich. He says that (a) salvarsan is a dangerous remedy 
in the acute stages of all forms of labyrinth disease whether syphilitic 
or non-syphilitic; (b) in acute exacerbations of subacute labyrinth 
disease it is also a dangerous remedy, whereas (c) in chronic disease 
of the labyrinth and auditory nerve it is a safe and valuable remedy. 

Brenario, however, has shown that in 10 cases of auditory nerve 
lesion (attended by deafness) following the mercurial treatment, 8 were 
relieved by injections of salvarsan, 2 of them partially, 6 completely, 
while the remaining 2 cases were not favorably influenced. It has also 
been demonstrated that cranial nerve involvement has been markedly 
diminished since larger doses of salvarsan have been administered, and 
since greater care has been exercised in its preparation. 

Faulty technique of preparation and administration of salvarsan 
seem, therefore, to be the chief determining factors in the causation 
of cranial nerve lesions. It may, therefore, be given with safety in the 
acute stages of labyrinthine disease, provided a fresh sterile solution 
of salvarsan is employed in sufficiently large quantity to destroy the 
spirochsetse within the sheaths of the auditory, optic, and other cranial 
nerves. 

INJURIES TO THE LABYRINTH; CONCUSSION OF THE LABYRINTH 

Etiology. — The injury may be due to direct or to indirect violence, 
more commonly the latter. The violence may be transmitted through 
the bones of the head to the internal ear, or through the air and ossicles 
in the middle-ear cavity, when there is & sudden condensation of the 
atmosphere by a great explosion, or a Moid of the hand over the ear. 
The bony capsule may be injured while the membranous labyrinth is 
unharmed, and vice versa. When a fissure of the skull passes through 
the labyrinth it usually extends to the middle ear and external auditory 



INJURIES TO THE LABYRINTH 1011 

meatus, hence the leakage of cerebrospinal fluid into the middle ear 
from which it escapes through the Eustachian tube or the ruptured 
membrana tympani. Great violence may produce pronounced aural 
disturbances without fracture of the bone. In these cases it is probable 
that the terminal nerve filaments of the labyrinth are irritated, and 
that small hemorrhages occur in the labyrinth. 

Injuries to the labyrinth from powerful compression of the atmosphere 
by explosions, boxing the ears, etc., may or may not cause rupture of 
the drumhead. Should the drumhead rupture, however, the labyrinth 
is probably saved from some of the force of the concussion, as the air in 
the middle ear escapes through the rupture, thus relieving the tension 
which would otherwise expend itself upon the foot plate of the stapes 
in the oval window. 

Detonations from heavy ordnance, or loud reports of guns in shooting 
galleries, produce a great deal of harm to the terminal nerve filaments 
of the labyrinth by irritation, and result in more or less deafness and 
tinnitus (Sexton). 

Symptoms. — The symptoms vary w T ith the severity of the concussion 
and the location and character of the lesion. If the concussion is power- 
ful the individual may drop to the ground as though shot, and remain 
in an unconscious condition for several hours, after which conscious- 
ness returns, and he finds himself to be entirely deaf. Or, if the con- 
cussion is light, he may stagger, but not fall, and be stupid or dazed 
for a short time, with more or less tinnitus and deafness. There may 
also be nausea and vomiting, with more or less giddiness and nystagmus. 
(See Chapter XXXIII.) If the blow or concussion causes fracture 
through the cochlea or semicircular canals sudden and total deafness 
on the affected side, a staggering gait, and nystagmus will be the promi- 
nent symptoms. The nystagmus gradually subsides and altogether 
disappears in a few days or weeks. 

The hearing for high tones is lost. Diplacusis and hyperesthesia 
acoustica are sometimes present. The sensibility of the skin of the 
auricle and meatus may be diminished. 

According to Politzer, "a medicolegal decision as to the existence of 
concussion of the labyrinth can be given only in those cases in which 
there is a fissure of the temporal bone extending to the external meatus, 
and in which an injury of the labyrinth may be inferred, either from 
the discharge of cerebrospinal fluid or from complete deafness and the 
absence of perception through the cranial bones." In the cases due to 
compression of air in the external meatus no opinion can be given 
(Politzer). It should be said, however, that since the functional tests 
of the vestibular apparatus have been formulated, an opinion of some 
value is possible. (See Functional Tests of the Vestibular Apparatus.) 

It may be of medicolegal importance to establish the degree of im- 
pairment of hearing, as the patient may seek redress in the courts. If 
he does so he will sometimes be tempted to magnify his auditory dis- 
ability. By the use of a series of tuning-forks, whistles, and other func- 
tional tests of hearing a correct diagnosis may be made. It will also be 



1012 THE EAR 

necessary to establish as nearly as possible the condition of his hearing 
apparatus before the injury. Lateralization of the sound in Weber's 
experiment to the injured ear signifies that the labyrinth is unaffected, 
whereas lateralization toward the sound ear is strongly suggestive of 
labyrinthine involvement in the injured ear. The loss of high tones 
in the affected ear also points to labyrinthine disease or injury. It 
is also necessary to prove or disprove the presence of labyrinthine dis- 
ease before the date of the injury. This is not often easy to do. The 
Rinne test is of little value when there is complete deafness, but may 
prove of some value when there is only partial deafness. (See Barany's 
Test.) 

Treatment. — Rest in bed consitutes the whole of the treatment in 
most cases, whether there is simple concussion or fracture through the 
labyrinth. Pain in the ear may be controlled with leeches applied to the 
mastoid region. Tinnitus of an aggravating character may be relieved 
by the administration of bromide of soda. After the acute symptoms 
have subsided iodonucleoid or iodide of potassium should be adminis- 
tered to hasten the absorption of the inflammatory exudate. 

OCCUPATION DEAFNESS 

For many years it has been recognized that among those who have been 
engaged in certain occupations for a long time, especially where contin- 
uous or frequently recurring sounds are heard, there is apt to be more or 
less deafness. The terminal nerve filaments of the labyrinth are con- 
tinuously subjected to irritation, and undergo a degenerative change often 
amounting to complete atrophy, and consequent deafness. Occupation 
deafness has been observed among blacksmiths, locksmiths, telephone 
operators, boilermakers, certain machine-shop workers, weavers, and rail- 
road employees. Among this class of workers it is probable that the 
continuous noise to which their ears are subjected causes an irritation 
of the acoustic nervous apparatus of the labyrinth and to the circulatory 
apparatus as well, which after a long time causes a disturbance of the 
nutrition of the parts, and finally leads to degeneration, atrophy, and 
paralysis. Both ears are usually affected. 

There are other conditions, peculiar to certain occupations, which 
cause dulness of hearing, as exposure to damp, cold atmosphere, dust, 
and superheated air. Stokers and engineers are particularly exposed to 
atmospheric changes, heat, cold, dust, and noxious vapors. They are, 
therefore, subject to nasal and epipharyngeal catarrh, and its extension 
to the Eustachian tube and middle ear. Many, after from five to ten 
years' service on railroads, have well-marked dulness of hearing. Numer- 
ous observers have written on the subject, and their conclusions are as 
follows: (a) The deafness and tinnitus may be due to the constant 
vibratory movement of the locomotive, resulting in irritation to the 
terminal nerve filaments of the labyrinth; (6) constant straining of the 
ears to hear above the noise and roar of the train, is thought by some to 



SIMULATED DEAFNESS 1013 

be a cause; (c) cold draughts of air and the heat from the furnace cause 
epipharyngeal and aural catarrh; and (d) the inhalation of the noxious 
gases and vapors cause irritation and catarrhal inflammation of the nose, 
pharynx, and middle ear. 

The chief symptom of the catarrhal cases of occupation deafness are 
more or less dulness of hearing, tinnitus, and in some cases giddiness. 
Rinne may be positive or negative according to the degree of deafness 
present. Hearing by bone conduction is increased. If the labyrinth is 
also involved the tests are somewhat confused, especially as to the rela- 
tive length of air and bone conduction, both of which are diminished. If 
there is also loss of hearing for high tones, the labyrinth may be safely 
said to be affected. 

SIMULATED DEAFNESS 

Various motives lead to simulation of ear disease. Hysterical individ- 
uals sometimes do it to excite attention or sympathy. Soldiers in the 
army and men drafted to fill the ranks, who desire to avoid duty, and 
those injured on railways, streets, and in shops, who wish to collect 
damages through the courts, sometimes exaggerate or assume deafness 
or artificially produce ear disease. 

Tests for Simulated Deafness.— (a) First make a careful objective 
examination of the external ear, external auditory meatus, drumhead, 
and the Eustachian tube. It is a significant fact that in the army most 
cases of suspected simulated deafness are unilateral. This arises from 
the fact that a double deafness would have previously attracted atten- 
tion, whereas a one-sided deafness might have existed without being 
discovered. In other words, it is easier to simulate one-sided deafness, 
hence its greater frequency among malingerers. The malingerer often 
artificially produces an obvious cause for the deafness he wishes to 
assume by dropping strong solutions of silver nitrate, carbolic acid, 
creosote, tincture of cantharides, etc., into the meatus. The skin and 
drumhead are thus cauterized and simulate in some degree suppura- 
tive otitis media. A careful examination will usually reveal the source of 
the inflammation. If silver is used, a dark brown stain will be seen; 
whereas if carbolic acid is used, the bleached skin will aid in arriving 
at a correct conclusion. A bandage placed over the ear and sealed, 
will in these cases lead to a speedy recovery, as the malingerer is unable 
to continue the caustic applications. Foreign bodies placed in the 
meatus to simulate deafness and ear disease may be detected by a careful 
examination. 

(b) It is in cases in which there are no objective signs of ear disease 
that the real difficulty of detecting malingering arises. The would-be 
patient often studies the subjective signs of labyrinthine deafness so 
well that, if he is especially shrewd, it is well-nigh impossible to detect 
him. In making the examination of this class of cases the eyes of the 
suspect must be bandaged, thus rendering it somewhat difficult for 
him to judge distances in testing with the voice, acoumeter, or watch. 



1014 THE EAR 

If he hears the instrument at greatly varying distances with the deaf 
ear (the other being tightly plugged) it is fair to presume he is malinger- 
ing. If, on the other hand, during repeated short testings, he hears at 
about the same distance, it is fair to presume that he is really deaf. 

(c) Erhard's Test. — When a normal ear is tightly closed a loud ticking 
watch (the Ingersoll watch) may be heard at three or four feet. The 
patient should have the supposed deaf ear tightly closed, and when the 
watch is within three or four feet of the normal ear, he should be com- 
manded to count the beats, which he will, of course, readily do. The 
sound ear should then be closed, the supposed deaf one being open, and 
the same test made on the open deaf ear. If when the watch is within 
two or three feet of the ear he says he does not hear it, it is fair to pre- 
sume that he is simulating the deafness, as at that distance he would 
hear the watch with the closed normal ear. 

(d) Chimani-Moos Test. — In one-sided deafness a large vibrating c 2 
fork is alternately held at an equal distance from each ear, until the 
suspected malingerer makes it plain to himself that he hears the fork 
loudest before the normal ear. The vibrating fork is then placed on 
the vertex, bridge of the nose, or median line of the incisor teeth, and 
the patient is asked in which ear he hears the fork the plainer. A 
patient with true unilateral middle-ear disease will, without hesitation, 
say that he hears it louder on the affected side; whereas a malingerer 
will hesitate, as he hears it equally well on both sides, or he may say he 
does not hear the fork at all in the suspected ear. The normal ear should 
now be tightly closed and the vibrating fork again placed on the median 
line of the skull, and the malingerer will probably say he does not hear 
it at all, or but faintly; whereas in true one-sided deafness the patient 
will say he hears the tone louder in the affected side. This only applies 
to disease, or simulated disease, of the middle ear. If disease of the 
labyrinth is being simulated, the problem becomes more difficult. 

(e) A common stethoscope, having one tube closed with a wooden 
plug, may be used to detect simulated unilateral deafness. The stetho- 
scope should be adjusted to the patient's ears, the open tube leading to 
the suspected ear, the closed one to the normal ear. The physician should 
now speak into the bell of the stethoscope, having the patient repeat what 
he hears. The instrument should then be removed, the normal ear 
tightly closed, and the same formula repeated to the patient. He will say 
he cannot hear, whereas he has already repeated after you, with the nor- 
mal ear tightly closed with the plugged arm of the stethoscope. In other 
words, he heard with his suspected ear through the open tube of the 
stethoscope (the one leading to the normal ear being tightly closed), 
thinking, of course, that he would lead the examiner to believe he heard 
with the normal ear. 

(J) The use of four ear specula, two open and two half filled with wax, 
may be used to detect malingering. The patient should sit with bandaged 
eyes facing the wall. The two open specula should be simultaneously 
introduced, one in each ear, and the examiner (behind the patient) 
should repeat certain words, or numerals, at varying distances, and 



PARESIS AND PARALYSIS 1015 

thus ascertain his hearing distance with both ears open. He should 
then change the specula, using one open and one closed, then two open, 
then two closed, and so on, noting the distances he hears with the vary- 
ing combinations of the specula. In this way the patient will unwittingly 
reveal the true condition of his hearing apparatus. 

Repeated examinations and the striking contradictions made by the 
malingerer during the various examinations will lead to a correct diag- 
nosis in most cases. 

Barany's Test. — Barany's noise apparatus may be used to detect 
malingering in one-sided deafness. The patient reads some selected 
paragraph or article aloud. So long as he hears his own voice it does 
not change in pitch or articulation. The noise apparatus is then applied 
to his sound ear while he continues reading. If he is actually deaf in 
the so-called affected ear his voice will become elevated in pitch and 
the articulation blurred. If he hears with that ear his voice will remain 
unaffected. This test may be made experimentally upon normal 
individuals by using two Barany apparatuses. At the beginning of 
the reading one is applied to the right ear. After a few sentences 
are read the other is applied to the left ear, thus rendering the patient 
totally deaf. His voice and articulation will be greatly modified. 



PARESES AND PARALYSES 

Angioneurotic Paralysis of the Auditory Nerve.— This is probably 
a rare affection, or, at least, it has been rarely recognized and described. 
It is characterized by a transitory facial pallor, nausea, dizziness, tin- 
nitus, and deafness. The attack lasts but for a few minutes, and when 
it disappears, the hearing is perfectly normal. The attacks may occur 
at frequent intervals. 

The treatment consists in the administration of sedatives, tonics, and 
the application of galvanism over the cervical sympathetica, which have 
an intimate anatomica2 connection with the terminal nerve endings in 
the labyrinth. 

Rheumatic Paralysis of the Auditory Nerve. — This is an obscure 
affection and difficult to diagnosticate. The diagnosis must largely 
depend upon the history of rheumatism elsewhere in the body, and upon 
the involvement of other cranial nerves. It may, however, in rare 
instances involve the auditory nerve alone. Bing reports a case limited 
to the auditory nerve and the clinical picture was as follows : (a) Female, 
aged forty-seven years, exposed to a draught, (b) Complete deafness, 
and tinnitus in the right ear, the left being less affected, (c) Weber 
lateralized to the left ear. (d) Inflation of the middle ear did not increase 
the hearing distance, (e) The case ended in recovery in eight days from 
the internal administration of the iodide of potassium and the applica- 
tion of vesicants to the mastoid region. It should be remarked that ii] 
these cases there is an absence of the objective signs of middle-oar 
disease. 



1016 THE EAR 

Symptoms. — The symptoms are those given above, with the addition 
of the history of rheumatism elsewhere in the body, the involvement of 
the facial or other cranial nerves, and the signs of labyrinthine involve- 
ment, as lessened, or loss of bone conduction. If the vestibular portion 
of the labyrinth is affected, there will be dizziness or a staggering gait 
and spontaneous nystagmus; whereas if the lesion is limited to the 
cochlear portion of the labyrinth, deafness and tinnitus will be the chief 
symptoms. 

Hysterical Paralysis of the Auditory Nerve.— This form of ear 
disease is usually unilateral, and is characterized by unilateral deafness, 
with tactile hyperesthesia, hyposmia, contracted field of vision, and 
diminished sensibility of the skin on the affected side. The Eustachian 
tube, drumhead, external meatus, and auricle are occasionally hyperes- 
thetic on the affected side. Weber experiment: tone lateralizes to the 
normal ear, bone conduction being diminished on the side of the paralysis. 
Whispered speech can often be heard at six or eight feet, while the tuning- 
fork may not be heard at all. This is considered by Hammerschlag as 
characteristic of hysterical paralysis. The same observer calls atten- 
tion to the fact that a tuning-fork vibrating at its greatest intensity before 
the affected ear ceases to be heard, and then after a few seconds is 
heard again. This, he explains, is due to fatigue of the auditory nerve, 
which after a few moments' rest perceives the sound again (Politzer). 

Slight aural lesions in hysterical individuals may give rise to marked 
disturbance of hearing. Tinnitus and dizziness, however, are signs of 
organic labyrinthine disease. In hysterical deafness the degree of 
deafness varies greatly at different times. 

Treatment. — The treatment of hysterical deafness should embrace the 
relief of any middle ear disease found, no matter how slight in character, 
as great improvement, all out of proportion to the apparent lesion, often 
follows. The nervous and general systems should be built up by tonic 
and sedative remedies, outdoor life, bathing, etc. The iodonucleoid or 
the iodide of potash should be given in 3 to 6 grain doses three times 
daily. Galvanism of the ear and sympathetic system of the neck may 
also be used to some advantage. 



NEUROSES OF THE AUDITORY APPARATUS; HYPERESTHESIA 

1. Hyperacuteness of Hearing. — Oxyecoia is a rare form of hyper- 
esthesia and is characterized by a temporary ability to hear music, or 
at least certain tones, at a much greater distance than others do with 
normal hearing. It is usually caused by alcoholic and tobacco poisoning, 
and is specially prone to occur in hysterical and neurasthenic persons. 

2. Paracusis. — Paracusis may be due to a disorder of the nervous 
apparatus, the labyrinth, or to a disturbed tension of the drum-head and 
ossicles of the middle ear. In this condition there is a false interpre- 
tation of the pitch of a tone, often amounting to J or \ interval. 






NEUROSES OF THE AUDITORY APPARATUS 1017 

Paracusis duplex, or diplacusis, is a variety of disturbed perception of 
pitch, and is characterized by the hearing of two tones for every sound 
produced, or in certain cases only for certain tones. It is due to certain 
unknown influences in the course of acute otitis media, serous middle- 
ear catarrh, chronic suppurative otitis media, and hyperostosis of the 
bony capsule of the labyrinth. 

Paracusis Willisii is characterized by the ability to hear better in a 
noisy place, as on a railway train, street car, or in a machine shop. Its 
etiology is still a mooted question, although it is commonly present in 
sclerosis of the middle ear and in hyperostosis or spongifying of the bony 
capsule of the labyrinth. Some hold that the improved hearing in the 
presence of noise is due to the increased excitability of the terminal 
nerve filaments of the labyrinth, while others hold that it is due to the 
mechanical vibration of the bone and secondarily of the terminal nerve 
filaments, which increases their auditory power. Still others advance 
the theory that it is due to a shaking and loosening of the ossicles of 
the middle ear. 

George McBean advances the theory that, owing to the large size 
of the membrana tympani as compared to foot-plate of the stapes, all 
vibrations of wide amplitude in the air are transmitted to the endolymph 
with greatly increased force though lessened amplitude. This force 
is spent on the membrane of the round window (which is five times 
more movable than the stapedial foot-plate, according to Politzer) and 
also in the ductus endolymphatic^. 

As air vibrations are practically ever present, mass motions in the 
endolymph are also ever present, and the normal relation of the tectorial 
membrane to the hair cells of the organ of Corti must be in a moving 
liquid. 

In otosclerosis the bony fixation of the stapes in the oval window 
prevents these mass motions in the endolymph, so that the fluid is 
comparatively at rest and the tectorial membrane becomes changed in 
its normal relation to the hair cells. (See Shambaugh's Theory of Sound 
Perception.) 

In the presence of any heavy vibrations, as in riding on the cars, the 
endolymph is thrown into motion, which is permitted by the elastic 
membrane of the round window, so that artificially a mass motion is 
produced similar to the normal motion of the endolymph and the nerve 
terminations become more capable of responding to the normal stimuli 
of molecular vibrations. 

If the round window becomes involved in the sclerotic process all 
mass motion must cease and paracusis Willisii would be absent. 

The vibration of the cranial bones and the attending stimulation of 
the nervous apparatus and fluid contents of the labyrinth and cerebro- 
spinal spaces seem to the author to be the most rational explanation. 
We know from personal observation that mechanical vibration applied 
to the spinal column and the head improves the hearing in some cases. 
Whether this is due to a stimulation of the nutritional centres or to a 
stimulation of the nervous apparatus of the labyrinth is still an open 



1018 THE EAR 






question. We know also from personal observation that if these 
patients are placed in bed and given passive exercise (massage) and 
wholesome food for a few weeks their hearing will improve. 

3. Hyperesthesia Acoustica. — This condition is characterized by a 
disagreeable sensation when musical tones or sounds are heard. The 
condition is usually present in anemic and hysterical individuals, and 
in those convalescent from severe illness. It may be present in certain 
forms of neuroses, as hemicrania and trigeminal neuralgia. It is also 
one of the manifestations attending the administration of quinine and 
salicylic acid. 

4. Tinnitus Aurium, or Subjective Noises.— This is one of the 
commonest ear symptoms, and has been repeatedly referred to in this 
work in the descriptions of numerous ear diseases. Its exact etiology 
is obscure in spite of the large amount of literature on the subject. 
Various theories have been advanced, explaining its cause, the one by 
Shambaugh being the most lucid and satisfactory. 

He advances the interesting and ingenious theory that: "In the first 
place, the character of tinnitus aurium is usually that of an indefinite 
sound, like the wind in the forest or the rushing of water, sounds made up 
of a great complexity of tones and with no definite pitch. Clinically, these 
subjective sounds arise from a variety of pathological conditions. One of 
the best known causes of tinnitus is pressure applied to the conducting 
apparatus, so as to push the foot plate of the stapes into the oval win- 
dow. This results in tinnitus aurium of the indefinite character described 
above. What actually takes place when the stapes is thus forced into 
the oval window is. an increase in the tension of the intralabyrinthine 
fluid. The result of this alteration in tension must be a disturbance 
of the membrana tectoria (see Anatomy and Physiology of the Laby- 
rinth), which has apparently the same specific gravity as the endolymph 
when the latter is under normal pressure. The hairs from the hair cells, 
as have been shown, normally penetrate into the lower surface of the 
membrana tectoria. Any disturbance in this membrane, however 
slight, would, therefore, alter the normal relations existing between the 
membrane and the hair cells. It seems that such an alteration from the 
normal relation between the membrana tectoria and the hairs of the hair 
cells would constitute a stimulation of these cells. When the foot plate 
of the stapes is pushed into the oval window there would result a slight 
stimulation of perhaps all the hair cells in the cochlea. The result 
would be exactly what we meet with clinically, a tinnitus aurium of an 
indefinite character, like the wind in the forest or the roar of a sea-shell. 
When a sudden increase or decrease in the blood pressure results in 
tinnitus aurium, the cause is the same as when the stapes is pushed into 
the oval window. The explanation of the increase or decrease of the 
intralabyrinthine pressure is here quite evident. The tinnitus aurium 
arising from the administration of certain drugs is also plausibly explained 
in the same way as due to an alteration in the blood supply to the laby- 
rinth with the resulting alteration in the presence of the intralabyrin- 
thine fluid. The tinnitus occurring in Meniere's disease, where there has 



THE HEARING OF VOICES AND MUSIC 1019 

been an escape of blood into the cochlea, is also similarly accounted for 
by this conception of the physiology of tone perception. The disturbances 
in the function of hearing arising from an injury produced by a shrill 
whistle, or an explosion near the ear, are also readily explained. In the 
first place, when a permanent disturbance in hearing is thus produced, 
it can be readily accounted for by a partial severance of the relation 
between the membrana tectoria and hair cells, so that the hairs from a 
greater or smaller number of these cells project free in the endolymph 
and do not come in contact with the membrana tectoria, and therefore 
cannot receive the stimulation from impulses passing through the endo- 
lymph. On the other hand, when there results from such an injury a 
permanent tinnitus aurium, this is explained by a partial, not complete, 
severance of the membrana tectoria from the hair cells over a certain area. 
This alteration of the relation existing normally between the hair cells 
and membrana tectoria may result, as we have repeatedly pointed out, 
in a stimulation of these cells. This explanation appears all the more 
rational since the pitch of the tinnitus is often approximately that of the 
whistle which originally produced the injury." 

The external conditions which influence tinnitus are those which 
influence catarrhal diseases of the upper respiratory tract, namely, 
sudden changes in the weather and temperature, living in damp places, 
improper clothing, etc. Bodily conditions, as fatigue, exhaustion from 
heat or undue exposure to inclement weather, and bodily depression 
from overmental application, also aggravate the subjective noises. 

The character of the noises is as various as noises themselves, the 
usual form being a singing, whistling, chirping, popping, crackling 
sound, or like the noise of a railway train in the distance. Many other 
noises are described by patients. They may be intermittent or continu- 
ous. The remissions usually occur while the patient's mind is engrossed 
with other matters, hence they are less troublesome in the daytime. 
Some patients are so distressed by the noises that they are driven to 
desperate measures, even to suicide. 

In some cases the noises increase in proportion to the deafness, in 
others they cease with marked deafness, while in still others they continue 
to increase after the deafness is absolute. They may appear in persons 
who are not deaf, but who are nervous, or exhausted from overmental 
or physical exertion, or from grief. 



THE HEARING OF VOICES AND MUSIC 

Human voices and musical melodies are sometimes heard by persons 
who have some affection of the cortex of the brain, though rarely or 
never by subjects with an uncomplicated ear disease. An existing ear 
disease may aggravate the condition in the cortex of the brain; hence 
the cure of the ear disease is often attended by an improvement of the 
hallucinations. Some persons hear musical melodies repeated over and 
over which prove very annoying. The subjective hearing of human 



1020 THE EAR 

voices is more serious, and often the forerunner of melancholia or 
progressive paralysis. 

Prognosis. — The prognosis and also the treatment of tinnitus is em- 
braced in the various diseases in which it occurs as a symptom. It 
may be said in general, however, to be comparatively good in cases 
of simple middle-ear and tubal catarrh, and generally unfavorable in 
hyperostosis and labyrinthine diseases, in noises of cerebral origin, and 
where the arterial noises have existed for a long time. Paracusis Willisii 
is usually taken to indicate a well-marked adhesive process in the 
middle ear or in hyperostosis of the bony capsule of the labyrinth, and 
the prognosis is unfavorable except when suitable remedial measures 
are used early. In cases in which human voices and musical melodies 
are heard the prognosis is very grave, except in rare cases in which the 
relief of the noises follows the cure of the middle-ear disease. 

Treatment. — The treatment of subjective noises is as broad as the 
subject of ear and brain diseases, hence it will not be given further 
consideration. 

WORD-DEAFNESS OR SENSORY APHASIA 

This form of deafness is characterized by the ability to hear, with the 
loss of the power to distinguish words, and is thought to be due to a 
lesion of the cortex in a portion of the middle convolution of the left 
temporal lobe, or in the left gyrus of that lobe. It may be questioned, 
however, whether the auditory (acoustic) centre is so restricted in its 
distribution. When present, it is generally due to an encephalitis, an 
exudate following a hemorrhagic pachymeningitis, brain tubercle, or to 
an embolic softening of the brain. 

Types of Word-deafness. — (a) Amnesic aphasia is characterized 
by the loss of memory for things, or by the application of wrong names 
to objects, (b) Monophasia consists in the naming of all objects to 
which the attention is directed by the same name, (c) Amnesic agraphia 
is the inability to write words that are spoken, or the names of sur- 
rounding objects, and (d) the inability to repeat what is heard and 
understood, (e) Amusia is a term introduced by Knoblauch to indicate 
deafness for musical tones. It occurs more frequently than word- 
deafness, and is probably due to a lesion of the first and second convolu- 
tions of the left temporal lobe in right-handed persons. Word-deafness 
and tone-deafness may exist at the same time. In tone-deafness the 
amusia varies in degree from absolute loss of hearing for musical tones 
to false interpretations of them. 



DEFECTS OF HEARING DUE TO INTRACRANIAL TUMORS 

Brain tumors, especially of basilar origin, may give rise to disturb- 
ances of hearing by pressure upon, or stretching of, the auditory nerve 






NEOPLASMS OF THE INTERNAL EAR 1021 

fibers, and by causing an ascending neuritis of the auditory nerve. A 
lymph stasis at the origin of the auditory nerve may also cause aural 
disturbances (Gradenigo). This condition is similar to that which 
occurs in the optic papilla during an increase of intracranial pressure. 

Symptoms. — The symptoms are unilateral tinnitus aurium, deaf- 
ness, more or less complete, and dizziness. If the tumor involves the 
vestibular nerve, nystagmus to the opposite side will be produced. 
(See Chapter XXXIII.) Other symptoms not expressed through the 
auditory apparatus are a feeling of tightness in the head, glimmering 
or dull vision, pain or full feeling on the side of the head corresponding 
to the location of the tumor, slow pulse, choked disk, and motor and 
sensory paralyses over the areas supplied by the other cranial nerves, 
which are also usually more or less involved. 

Diagnosis. — The diagnosis must be made chiefly by the disturb- 
ances arising through the lesions of the other cranial nerves, as the 
aural symptoms are not characteristic of this form of ear disease. An 
early diagnosis, therefore, cannot often be made. Facial paralysis and 
retained perception for the tuning-forks, watch, and acoumeter through 
the cranial bones, together with dizziness, tinnitus, and deafness, are 
significant symptoms. The perception of the forks, watch, etc., through 
the cranial bones exclude labyrinthine disease, even of a mild type. In 
some cases the perception for high tones often remains unaffected, and in 
others it is diminished. The age of the patient should be taken into ac- 
count in connection with the tests of bone conduction and the hearing for 
high tones. If the patient is more than fifty years old there is a physio- 
logical diminution in the perception by bone conduction, as well as a 
restriction of the upper limit of hearing. (See Functional Tests of the 
Auditory (Cochlear) iVpparatus.) Hence, in a case with the above aural 
symptoms, in which there is a suspicion of brain tumor, the presence of a 
slight diminution of hearing by bone conduction and the loss of hearing 
for the higher tones would not necessarily lead to the conclusion that 
the labyrinth was affected by a brain tumor. As first stated, the chief 
diagnostic guide is the pareses or paralyses of the other cranial nerves, 
the facial nerve usually affording the most direct and certain informa- 
tion. A slight paresis and anesthesia of the skin over the area of nerve 
distribution, when found in conjunction with deafness, tinnitus, and 
dizziness, usually points strongly to an ear disturbance having its origin 
in tumor of the brain. 



NEOPLASMS OF THE INTERNAL EAR 

Newgrowths in the internal ear may be primary (rare) or secondary. 
Primary growths at the root of the acoustic (auditory) nerve have been 
reported, but nearly all accurately reported cases have been secondary. 
Epitheliomata and malignant round-cell sarcomata may extend from 
the middle ear to the labyrinth, and destroy the cochlea, vestibule, or 
even the whole of the petrous portion of the temporal bone. Neuromata 



1022 THE EAR 

of the auditory nerve have also been observed. Cavernous angiomata 
of the petrous portion of the temporal bone have been reported by 
Politzer but are extremely rare. 

The symptoms vary with the location and size of the growths, and are 
deafness, tinnitus, dizziness, staggering gait, nausea, nystagmus and 
vomiting, together with other extraneous symptoms due to lesions of 
the other cranial nerves. 



LOCOMOTOR ATAXIA DEAFNESS 

Disturbances of hearing occurring in the course of locomotor ataxia 
are due to atrophy of the auditory nerve. The atrophy may affect 
the nervous apparatus anywhere from its cortical origin to its distri- 
bution in the labyrinth. According to various statistical reports, the 
hearing is affected in tabes dorsalis in from 1 to 80 per cent, of the cases 
recorded. The aural symptoms usually develop gradually. The tin- 
nitus is always present and almost unbearable. The affection is usually 
bilateral, and dizziness is present in about 65 per cent, of the cases. 
The author recently examined a case in which there was deafness, 
intolerable tinnitus, and dizziness. The bone conduction and upper 
range of hearing were diminished, but not more than the age of the 
patient (sixty-five years) would account for. Rotating the head on its 
various axes with the eyes closed did not increase the dizziness or pro- 
duce nystagmus. The appearance of the drumheads was normal. The 
hearing for low, deep-toned tuning-forks was normal, Rinnc negative, 
and both ears were affected. 



CHAPTER LV 

DEAF-MUTISM 

Holger Mygind's elaborate and classical treatise on deaf-mutism 
opens with the following paragraph: 

Definition. — "Deaf -mutism, strictly speaking, signifies the abnormality 
which is characterized by the co-existence of deafness and dumbness. 
Various circumstances necessitate, however, a more limited definition. 
Deaf-mutism may, therefore, be defined as a pathological condition 
dependent upon an anomaly of the auditory organs, either congenital 
or acquired, in early childhood, causing so considerable a diminution 
of the power of hearing as to prevent the acquisition of speech; or, 
should speech have been acquired before the occurrence of the loss 
of hearing, it is preserved by the aid of hearing alone. Individuals 
exhibiting this pathological condition are described as deaf-mutes, even 
when speech has been acquired by a special system of instruction." 

The foregoing definition will be observed in the consideration of this 
subject. 

Historical. — It is interesting to know, as Mygind has shown, that 
deaf-mutism has been referred to in literature from the time Exodus 
(fourth chapter and second verse) was written. Herodotus, Hippoc- 
rates, Aristotle, Pliny, Gellius and others of the ancient period refer 
to it; and in the Middle Ages, Cananus, Pedro de Ponce, Andreas 
Laurentius, and Zachias. 

A gradual change of opinion as to the relationship between hearing 
and speech took place. In the ancient period the idea prevailed that 
it was due to the inability to use the tongue (Hippocrates and Aristotle). 
Later, Pliny said, "The man who is born without the power of hearing 
is also deprived of the power of speech, and none are born deaf who 
are not also dumb." 

During the Middle Ages the influence of Aristotle's writings was so 
potent that little progress, beyond the opinion expressed by him, was 
made. Cardanus, 1501 to 1576, first distinctly stated the true relation- 
ship, i. e., that deafness is the principal and primary cause of deaf- 
mutism. 

During the last century, the subject was placed upon a scientific 
basis, chiefly through the writings of Itard, Schmalz, Wild, Meissner, 
Toynbee, von Troltsch, A. Hartman, Lemcke, and Mygind. 

It is true that institutional work and statistical bureaus have aided 
very materially in the evolution of the subject. The classical work of 
Mygind probably represents the most advanced and correct statement 
on the subject that has been given, and it is chiefly from his work that 

( 1023 ) 



1024 THE EAR 

the author gleans the data for this chapter. Direct reference is also 
made to the works of von Troltsch and Toynbee. 

Classification. — Deaf-mutes may be best classified according to the 
degree of deafness as: 

(a) True deaf-mutes, or those who are totally deaf to speech, and 
must depend entirely on the other senses to acquire its use. 

(b) Semi-deaf-mutes, or those who have slight power of hearing, or 
who retain slight speech acquired before deafness supervened. 

Some confuse those who, for other reasons than deafness, have lost the 
power of speech with deaf-mutism. It should, therefore, be distinctly 
understood, without question, that deaf-mutism refers to those who have 
lost or failed to acquire speech on account of deafness. 

Another classification, which is perhaps better as a practical working 
basis, is that adopted by Mygind, namely: 

(a) Congenital deaf-mutism. 

(b) Acquired deaf-mutism. 

The first class refers to those who are born with some defect of the 
organ of hearing, which, according to modern statistics, includes about 
50 per cent, of all the cases. Mygind thinks this estimate too high, as 
many of the so-called congenital cases are, in all probability, due to some 
intercurrent disease of the ear which destroys the hearing before articu- 
late speech is acquired, ^nile the author's observations have been 
comparatively limited, they have nevertheless been sufficient to recognize 
the difficulties to be encountered in determining whether certain cases 
belong to the congenital or to the acquired class. The author is, there- 
fore, inclined to agree with Mygind that 50 per cent, is too high an 
estimate to be placed upon the relative proportion of congenital as 
compared with the acquired types of deaf-mutism. 

The relative proportion of deaf-mutes to the total population of the 
various countries in which statistics are to be found varies from 34 
(Holland) to 245 (Switzerland) per 100,000 inhabitants. The average in 
European countries is 79, while in the United States it is 68 per 100,000 
inhabitants. 

Etiology. — The great variation in the relative number of deaf-mutes 
in the different countries seems to point to certain localities as pre- 
disposing to it. Old geological (Escherich) formations, as found in the 
Alps, were formerly thought to be the cause, but more careful investiga- 
tions have shown this to be incorrect. In Switzerland, where the rate is 
so high, it is due to the endemic cretinism so prevalent there. This 
phase of deaf-mutism is not included in the consideration of this subject. 

Climate probably has no influence.' 

Unfavorable social and hygienic conditions play a very important part 
in the etiology of deaf-mutism. 

H. Schmaltz emphasizes this in his work on Deaf-mutism in Saxony. 
In conclusion, he says: "The industrial population, and especially that 
part of it which is worse off from a pecuniary point of view — in fact, all 
who are in danger of degenerating both morally and physically on 
account of insufficient means, or poverty, and who, consequently, are 



DEAF-MUTISM 1025 

unable, or unwilling, to take the necessary care of their children — all 
such persons exhibit the highest percentage of deaf-mutes among their 
descendants. Finally, we found that when, in addition to all these 
unfavorable conditions under which children are born, they are brought 
up by a family which, for various reasons, is perhaps already more or 
less degenerated, and have to undergo all sorts of diseases in infancy 
without having sufficient power of resistance, then deaf-mutism is an 
only too common result." 

Heiediiy undoubtedly influences the number of deaf-mutes. Mygind 
very tersely expresses the present status of our knowledge on this point 
in the following words: "Deaf-mutism is comparatively frequent among 
the relatives of the deaf-mutes; it is least frequent in the direct ascend- 
ing line (grandparents, parents) ; more frequent in the collateral branches 
(great-uncles, great-aunts, uncles, aunts, cousins, parents' cousins, 
and second cousins); and most frequent by far among the brothers and 
sisters of the deaf-mutes. This is in exact accordance with the result 
of an investigation into the appearance of deaf-mutism among the 
relations of congenital deaf-mutes; from this and many of the facts 
above mentioned, we are justified in supposing that the manner in which 
deaf-mutism appears in different generations is a result of certain 
qualities appertaining to its congenital form." 

It is not assumed that deaf-mutism per se is transmitted by hereditary 
influences, but that certain anatomical or nervous states are retained to 
some extent, and that these may result in deaf-mutism — that is, deaf- 
mutism is influenced by the transmission of a predisposition to certain 
ear diseases and to certain nervous disorders. These, in combination, 
tend to produce the affection. 

Consanguineous marriages seem to influence the number of deaf- 
mutes, as is shown in the following table: 

Forty-seven Marriages between Blood Relations Produced 
Seventy-two Deaf-mutes 

1 marriage between aunt and nephew produced 3 deaf-mutes. 

4 marriages " uncle and niece " 11 " 

26 " " first cousins 3 " 

16 " " second cousins " 20 " 

Statistics prove that the influence of consanguineous marriages is 
entirely limited to congenital deaf-mutism. 

Various diseases in parents, as alcoholism, syphilis, general debility, 
epilepsy, insanity, etc., are etiological factors in the production of deaf- 
mutism. The offspring of such parents do not receive in utero the vital 
energy necessary to resist the vicissitudes of life after birth. They are, 
therefore, more liable to be injured by infections and nervous diseases 
than the offspring of healthy parents. It may be said in this connec- 
tion, however, that the parents of deaf-mutes are often remarkably 
healthy and robust individuals. 

Hemophilia and deaf-mutism are rather commonly associated among 
the offspring of marriages producing a large number of children. 
65 



1026 THE EAR 

The death rate is higher among children in families in which there are 
deaf-mutes, probably on account of the stigmata of degeneracy, and 
because suppurative otitis media adds to the mortality rate. 

Mygind cites statistics to show that first births produce more deaf- 
mutes than either the second, third, fourth, or fifth. Other weaknesses 
are also more common among the first born. 

Maternal impressions do not appear to exert a marked influence in the 
production of deaf-mutism. 

Immediate Causes of Deaf-mutism. — The age at which most cases 
of deafness occur in the acquired type is from the first to the fifth years, 
more occurring in the second and third years. In the United States the 
greater number occur in the third year. 

Brain diseases, more particularly simple meningitis and epidemic 
cerebrospinal meningitis, are the chief causes of the acquired deaf- 
mutism. From 12 to 26 per cent, of the European cases have been 
attributed to epidemic cerebrospinal meningitis. Moos and Knapp 
were the first to call attention to this disease as one of the causes of 
deaf-mutism. 

Deafness may occur during epidemic cerebrospinal meningitis resulting 
from middle-ear or labyrinthine lesions. The former occurs more often, 
but is not so pronounced nor so permanent as that due to the involve- 
ment of the labyrinth. Deafness of middle-ear origin does not so often 
produce deaf-mutism on this account. Labyrinthine involvement 
usually occurs about the second week of epidemic meningitis, although 
it may occur at a much later period (Knapp, Mygind). The deafness 
occurs suddenly, in contradistinction to that in middle-ear deafness. 
Postmortem examinations have shown most of them to be due to inflam- 
mation of the membranous labyrinth. "This process leads partly to the 
more or less complete destruction of the contents of the labyrinth, and 
partly to the deposit of new tissue. The new tissue may be either fibrous, 
calcareous, or osseous, and may fill the normal cavity of the labyrinth 
either completely or partially." (Mygind.) 

The original cause of the disease is undoubtedly some microorganism 
which enters through the ear, nose, or epipharynx, although definite 
data is not yet at hand to confirm this statement. 

The equilibrium is often disturbed in deafness due to brain disease, as 
pointed out by Moos. This is due to the involvement of the semi- 
circular canals and other apparatus of the labyrinth. This may endure 
for years. 

Other acute infectious diseases, as scarlet fever, measles, yphus and 
typhoid fevers, diphtheria, smallpox, vaccination, chickenpox, erysipe- 
las, dysentery, influenza, malaria, whooping cough, mumps, croupous 
pneumonia, and rheumatic fever, directly or indirectly, cause infantile 
deafness. The inflammation first attacks the mucosa of the middle ear, 
which ulcerates, the bone beneath becomes carious, -and the meninges 
and labyrinth are thus exposed to infection. The ossicles of the middle 
ear, being covered by the mucous membrane, undergo the same changes. 
If the destruction does not involve the labyrinth, the deafness is not 
59 






DEAF-MUTISM 1027 

usually profound enough to cause deaf-mutism. If it involves the laby- 
rinth, the same changes described under cerebrospinal meningitis take 
place and result in complete and permanent deafness. If this occurs 
before speech is acquired, the child becomes a deaf-mute. 

In scarlet fever, measles, and kindred diseases, the infection enters the 
tympanum through the Eustachian tube. The labyrinth is usually 
invaded through either the oval or round windows, as has been shown 
in numerous autopsies by the scar on the membrane. In some cases, 
however, it appears that the middle ear is not involved, the drum mem- 
brane being normal. It is probable in these cases that the infection 
reached the labyrinth by metastasis. 

Smallpox does not account for many cases of deaf-mutism in those 
countries where compulsory vaccination is in vogue. It is barely pos- 
sible that vaccination may cause deaf-mutism. 

Connor collected the literature of labyrinthine disease caused by 
mumps up to 1884, and found 33 cases, 9 of which w T ere fifteen years 
of age or less. 

Certain constitutional diseases, more particularly syphilis, scrofula, 
and rickets, are occasional causes of deaf-mutism. Inherited syphilis 
causes it more often than is shown by the statistics, as it is difficult to 
ascertain the data concerning this affection. 

Fright, lightning-stroke, sunstroke, quinine poisoning, colds in the 
head, sudden immersion in water, and traumatisms occasionally cause 
deaf-mutism. A fuller knowledge of the causes of deaf-mutism should 
attain among physicians, as it is to them the parents will first appeal for 
information and relief. Many of the cases may be so educated as to 
make them useful members of society and a source of gratification 
to themselves and to their parents, if the needed advice or attention is 
given them at the proper time, i. e., while their minds are still in the 
imaginative and perceptive stages of development. (See Lip Reading.) 

Pathology. — Reliable postmortem examinations in 139 cases of deaf- 
mutism are on record. From these the following facts are gleaned 
(Mygind) : (The changes in the external ear and the auditory meatus will 
not be considered, as they could have but little to do with the causation 
of deaf-mutism.) In the drumhead, perforations, calcareous deposits, 
adhesions, thickening, and entire absence have been found. 

In the middle ear adhesive processes, calcifications, and ossification 
from intense inflammation have been found. The oval window is some- 
times filled in with a mass of bony tissue (hyperostosis), while the round 
window is contracted in size. The membrane of the round window is 
sometimes thickened, or thinned, scarred, calcareous, or absent. 

Osseous masses in the attic and other portions of the middle-ear cavity 
have been found. Caries of the bony walls of the middle ear from 
chronic suppurative inflammation are sometimes present. 

The ossicles are ankylosed, bound down by adhesions, necrotic or 
entirely destroyed, from suppuratn^e inflammatory processes, in a con- 
siderable number of cases. One or more of the ossicles may be absent. 
and the others present, the stapes alone being absent in a number of cases. 



1028 THE EAR 

^lien atrophy of the ossicula auditus is present, It is probably of 
congenital origin. 

Ankylosis of the ossicles is very often present. 

Atrophy and caseous degeneration of the tensor tympani and stapedius 
muscles is often found. The chorda tympani nerve is sometimes absent. 

The mastoid process is found to be affected, as elsewhere described 
under Suppurative Diseases of the Middle Ear and Mastoid Process. It 
is sometimes absent from arrested development. 

The Eustachian tubes are sometimes obstructed by fibrous or osseous 
tissue, as a result of repeated inflammations. 

The Labyrinth. — The most frequent pathological change found in the 
labyrinth is the deposit of osseous tissue from inflammatory processes. 
This is sometimes so extensive as to completely obliterate the labyrin- 
thine canals (Mygind), and gives rise to the idea that there is congenital 
absence of the labyrinth from arrested development (Montain, Michel, 
Schwartze, Moos). Chalky pigment and fibrous deposits are also 
found. 

Absence of the auditory nerve and labyrinth (partial or complete) are 
also reported. In one of Mygind's cases the labyrinth was completely 
filled with osseous tissue, except at certain portions where pus was 
present. It was due to a suppurative process following scarlet fever. 

The membranous labyrinth may be congenitally absent, as shown by 
Nuhn. 

The vestibule (excepting its aqueductus) is rarely involved, even in 
congenital cases. When an affection is present, the changes are inflamma- 
tory in origin. Pathological changes in the contents of the membranous 
vestibule have often been found. 

The aqueductus vestibuli may be distended, in which case the cochlea 
is also affected (Ibsen) while the vestibule is not, thereby suggesting 
an intimate relation between the aquseductus and cochlea rather than 
the vestibule. Habermann explains the distention of the aquseductus 
vestibuli as being due to pressure in hydrocephalus, especially when 
the petrous portion of the temporal bone is rachitic. 

The semicircular canals are quite commonly affected. 

Symptoms. —D eafness may be partial or complete. If partial, there 
may be hearing for sounds, noises, voice, or speech. One child, for 
example, may hear a loud noise and not hear speech, or vice versa; or 
he may hear the voice and not hear articulate speech. Again, he may 
hear tones of a certain pitch and not hear those of another pitch. 

As stated in the beginning of this chapter, the best classification is 
(a) true deaf-mutes, and (b) semi-deaf-mutes. In other words, those 
who have partial hearing and those who have total absence of hearing. 
It is often difficult to determine this point in young infants, for obvious 
reasons. In older ones it can be usually done by the use of bells, loud 
whistles, clapping hands, etc. The child will blink the eyes, or show 
by a change in its expression that it hears. 

A more accurate method of testing older deaf-mutes may be made 
with tuning-forks and whistles. The hearing should be tested by both 



DEAF-MUTISM 1029 

air and bone conduction. Hearing by air conduction is tested by hold- 
ing the vibrating fork near the external auditory meatus and noting 
the expression of the child; bone conduction is tested by placing the 
handle of the vibrating fork on the mastoid or the vertex of the head, 
the expression of the child being meanwhile watched for signs that it 
experiences a novel sensation. Other instruments, as the watch and 
the Politzer acounieter, may be used if there is considerable hearing 
present. The voice, especially the articulate vowels, is a good test when 
spoken close to the patient's ears, care being exercised to prevent them 
seeing the movements of the lips. If they hear the vowels, consonants 
and words may also be utilized. 

Semi-deaf-mutes hear better at certain times than at others, for the 
same reason that those with less pronounced middle-ear disease have 
variations in hearing. 

The various reports as to the relative number of the totally deaf 
and partially deaf in the various statistical publications are not reliable, 
as different tests have been used to determine these facts. There are 
more cases of profound or total deafness among the acquired than the 
congenital cases, probably on account of the great severity of postnatal 
processes in the ear. 

A very significant fact has been announced by Urban tschitsch, namely, 
that children who had previously reacted to no sound whatever, after 
certain acoustic exercises, were capable of hearing. This points to the 
fact that a sensory tract is developed by use. Its powers, or functions, 
may lie dormant for years, and then be aroused to activity and develop- 
ment. The fact that a child never has heard is not necessarily proof 
that it never will. 

Mutism may be the result of the deafness, or it may be due to the 
same influences which caused the deafness. There may be an arrested 
or perverted development of the vocal organs, coincident with the dis- 
turbed development of the ear; or aphasia may be due to a congenital 
or acquired lesion of the brain. If the speech centres of the brain were 
injured at the time the ear was affected, the child can never be taught 
to speak clearly. 

The age at which deafness must occur to produce mutism is not to 
be stated arbitrarily, as the capacity to learn speech varies greatly in 
different children. Hartmann says that if deafness occurs before the 
seventh year, mutism is apt to follow. The slight speech already acquired 
will gradually disappear unless special pains are taken to cultivate it. 

The speech of deaf-mutes is peculiar, lacking in proper accentuation, 
which renders it monotonous. The respiratory act is deficient, and 
the voice feeble. The greater the deafness the more pronounced the 
peculiarities of the speech become. True deaf-mutes, as well as 
semi-deaf-mutes, may be taught articulate speech, which is known as 
"articulation." Deaf-mutes experience great difficulty in retaining 
"articulation" when they leave the school-room and mingle with those 
who can scarcely understand them. Articulation is quite different from 
ordinary speech, and it is only after hearing it used to a considerable 



1030 THE EAR 






extent that one learns to understand it. This is one of the difficulties 
in the way of its more general use among deaf-mutes. Lip-reading is 
learned at the same time as articulation, but, as it requires close atten- 
tion and good sight, it is also often abandoned when contact with the 
world at large is established. 

Other ear symptoms, as tinnitus, giddiness, staggering gait, and 
otorrhea, are present in a certain number of deaf-mutes. Otorrhea is 
quite common, especially among the acquired cases. • 

Sequelae. — An impairment of the mental faculties may or may not 
be present. When it is remembered that a deaf-mute is barred from 
many avocations, it is easy to understand that ambition is thereby hin- 
dered. The temptation to idleness and dependence upon those more 
fortunate often stultifies the mental and moral faculties. The morbid 
processes causing the deafness may also impair other portions of the 
brain, and thus impair the mental faculties. About 50 per cent, of those 
who are deaf-mutes are notably deficient in mental power. 

The laryngeal muscles are slightly atrophied from non-use; otherwise 
the larynx is usually normal. 

The lungs of deaf-mutes seem to be less resistant than those of other 
children, as shown by the fact that so many of them die of tuberculosis. 
This is still further shown by stethoscopic examinations. Their breath- 
ing is more superficial and less rhythmical than in normal children. 
This is also true of children with normal ears who have defects of speech, 
such as stammering. 

Tuberculosis, scrofula, sterility, left-handedness, and diminution of 
muscular energy are commonly found among deaf-mutes. 

The auricle is rarely malformed in deaf-mutes, as it develops inde- 
pendently of the internal ear. The external meatus and membrana 
tympani show such changes as are incident to middle-ear diseases in 
general. The same is true of the Eustachian tube and mastoid process. 

Adenoids and catarrhal affections of the nose and epipharynx do not 
seem to be more common among deaf-mutes than other children. That 
there is a direct relation between infections which enter the middle 
ear through the epipharynx and Eustachian tubes there can be no 
doubt. The same irritation causes the adenoid tissue to enlarge, a 
fact which explains the apparent etiological relationship of adenoids to 
deaf-mutism. 

Boucheron advances the ingenious theory that deaf-mutism may be 
caused by otopiesis, meaning thereby deafness by " producing exhaustion 
of the air in the middle ear as the result of the closing of the catarrhally 
affected Eustachian tubes, which process, again, causes overpressure in 
the inner ear, and consequently degeneration of the terminations of the 
auditory nerves." (Mygind.) 

There are other abnormalities coincident with deaf-mutism, such as 
malformation of the cranium, the eye (retinitis pigmentosa, hemeralopia, 
"hen-blindness," panophthalmia, etc.), thyroid gland, nerves, and bones. 
They are largely the result of the same influences which primarily cause 
deaf-mutism. 



DEAF-MUTISM 1031 

The relationship between idiocy and deaf-mutism is not that of cause 
and effect, as they are both the result of the same primary influences. 
Deaf-mutism does not cause idiocy. 

Insanity is estimated (Wines) to be four times as common among 
deaf-mutes as in individuals in general. Mygind shows that this is 
probably due to the isolated social position and mental depression 
which naturally attend the loss of one of the chief senses. 

Diagnosis. — The diagnosis is easy in most cases, and is based on the 
following facts: 

(a) Deafness so pronounced that speech cannot be heard. 
(6) Deafness dates from birth or before the seventh year. 
(c) Deafness and fragmentary speech (semi-deaf-mutes). 

In infants it is difficult to make a diagnosis, as the child does not yet 
speak, and it is difficult to determine if it hears. Loud bells, clapping 
of hands, whistles, etc., should be used without letting the child see 
them, noting the blinking of the eyes or other signs that it recognizes the 
noises. A negative result is not, however, conclusive of deaf-mutism. 
Hartmann has called attention to the fact that some children do not 
have the organ of hearing fully developed at birth, the development 
being completed at the first year of extra-uterine life. 

Simple mutism (aphasia) may be mistaken for deaf-mutism upon 
casual examination, although it is seldom congenital or acquired in 
infancy. Careful examination will show hearing present. 

Simulation of deaf-mutism and hysterical deaf-mutism are rarely seen. 

Prognosis. — A few well-authenticated cases are recorded in which 
the hearing was improved. The great majority, however, are not 
thus favorably affected. The number of cases reported by men of the 
highest standing, as being so much improved that they regained enough 
hearing to carry on conversation with their fellows, warrants the use 
of every means within our power to alleviate all ear affections, with the 
hope that those under our care may also be thus favorably influenced. 
Some cases undoubtedly improve spontaneously. 

Speech will generally improve in proportion to the improvement in 
hearing. 

Treatment. — The treatment should be such as would be given to 
similar ear affections in those who are not deaf-mutes. Suppurative 
disease should receive special attention, to prevent it spreading to 
neighboring organs. Postnasal adenoids and other diseased processes 
of the nose and throat should receive appropriate attention according to 
the methods described elsewhere in this work. 

After having done all that can be done to improve the organ of hear- 
ing and the general system, the child should be sent to some institution 
of reputable standing, where he can receive suitable training in the 
acquirement of speech or other means of communication. Here he will 
also receive instruction in useful knowledge and manual training, which 
will fit him for a place in social and economic life. 

The prevailing methods of instruction are known as the German and 
French methods. The first is probably the best for a majority of deaf- 



1032 THE EAR 

mutes, as it teaches them articulate speech. There seems to be no 
doubt that the use of the vocal organs stimulates the development of the 
brain and motor tracts. Makuen has called attention to this fact. 
(See Defects of Speech.) The French method teaches communica- 
tion by means of signs. This is probably well adapted to some cases. 
The question of methods should, however, be left to those who are more 
intimately concerned to decide. It is not the physician's province to 
train these unfortunate children. His duty is to relieve the physical 
condition as nearly as possible and then recommend the parents to send 
the child to some reputable institution for deaf-mutes, assuring them 
that only in this way will he be fitted for a useful place in society. 



LIP READING 

Deaf-mutes, and persons so deaf as to understand conversation with 
difficulty, should be taught lip reading whenever possible. It has long 
been known that persons partially deaf watch the face of the one address- 
ing them, and by combining what they imperfectly hear with the move- 
ments of the lips, the facial expression, and the gestures of the speaker, 
they are enabled to understand what is being said. This suggested 
the advisability of reducing lip reading to a scientific basis, and schools 
for this purpose are now established in nearly all large cities. 

The acquirement of facility in lip reading necessitates the closest 
application on the part of the student, and the most painstaking and 
persistent effort on the part of the teacher; hence, there is little hope of 
success outside of a special institution for the purpose. The physician 
cannot give adequate attention to such patients, and he should recom- 
mend that they be sent to a school at as early an age as possible, as 
otherwise the patient will be greatly handicapped in the pursuit of his 
business in later life. As there are many charlatan schools advertising 
to give such instruction, the physician should first make diligent inquiry 
as to which are conducted upon scientific lines before making any 
recommendation. 

Lip reading may also be profitably studied by adult deaf persons 
whose early education in this respect was neglected. 



INDEX OF AUTHORS 



A 

Abels. Hans, 897 
Adami', 111, 127 
Alexander, 832, 891 
Allport, 841 
Andrews, A. H., 51, 194, 

616, 714 
Aristotle, 1023 
Arnold, 448 

Asch, 67, 68, 77, 78, 79 
Atkinson, 442 



Babinski, 488 

Bacon, 1008 

Ball, 349, 350, 402, 405, 408 

Ballance, 601, 733, 840, 

853, 854, 855 
Barany, 627, 628, 881, 882, 

891, 906, 908, 909, 910, 

911 
Bardeleben, 991 
Baron, 268 
Baumgarten, 324 
Beard, F., 376 
Beck, Emil, 98 
Beck, Joseph C, 43, 101, 

155, 158, 219, 220, 314, 

328, 329, 996 
Berard, 326 

Berens, T. Fassmore, 609 
Bezold, 616, 617, 622, 627, 

735 
Bickel, 331 
Bier, 127 
Bikeles, 479 
Bing, 628 
Blake, Clarence, 680, 681, 

741 
Bland-Sutton, 369 
Boenhaupt, 279 
Bono, 33, 34 
Bostoc, 548 
Bostroem, 326 
Bosworth, 57, 68, 70, 160, 

442, 444, 553 
Boubland, 551 
Bouche, 367 
Boyce, John W., 582 
Brandegee, 341 



Brauers, 558 
Braun, 903 
Brawley, 127, 196 
Briggs, 485 
Brindel, 333 
Broca, 766 
Brown, J. S., 652 
Brown, R. H., 95 
Browne, Lennox, 308, 310, 

349, 350, 354, 365, 368, 

370, 373, 503, 512, 545 
Bruce, 400 
Bruhl, 763 
Brunk, Thomas H., 684, 

688 
Brunnung, 891 
Bruns, 370 
Bryant, J. D., 444 
Bryant, W. S., 684 
Buchanan, T. Drysdale, 

589 
Burnet, 635 
Burnett, 446, 644 
Burns, B. V., 548 
Buck, 320 
Buck, A. H., 724 



Campbell," J. T., 376 

Cananus, 1023 

Canfield, 218, 236 

Cardanus, 1023 

Carel, 339 

Carter, 88 

Casselberry, 282, 358, 424 

Celsus, 637 

Charcot, 1003 

Charsley, 268 

Chiari, 329, 470, 500 

Chimani, 1014 

Church, J. F., 635 

Clark, C, 547 

Clark, J. Payson, 547, 548, 

549 
Coakley, C. G., 162, 473 
Cobb, C. M., 197 
Cobb, F. C, 25 
Coffin, 164 
Coghill, 309 

Cohen, J. Solis, 309, 508 
Cohen, R.,.537 



Cohen, S. Solis, 261 

Colburn, J. E., 187 

Conitzen, 369 

Connor, 1027 

Coolidge, Frederick, 25, 

347 
Cooper, Astley, 194, 230, 

733 
Corlin, 462 
Corwin, 227 
Cosolini, 443 
Crisp, 448 
Cunes, 551 
Cunningham, 563, 569, 

589 
Curtis, 470, 471, 527, 530 



Dabney, 127, 196 

Daly, William, 26 

Dawbarn, 377, 378, 558 

Dawson, 381 

Day, Ewing W., 943 

de Reske, Jean, 23 

Dehio, 309 

Delevan, 442, 548 

Delstanche, 760 

Demme, 309 

Dench, E. B., 762, 767, 793, 

854 
Denker, 233, 735, 737 
Depres, 320 

di Mendoza, Suarez, 690 
Dieulafoy, 380 
Duchemin, 533 
Duel, A. B., 689, 742, 743, 

815 
Dunbar, 262 
Dupuy, 680, 766, 767 



Edinger, 514 
Eisenlohr, 515 
Escat, 351 
Eschorich, 1024 
Esmarch, 360 
Evans, 533 
Ewald, 874 

(1033) 



1034 



INDEX OF AUTHORS 



F 

Faklow, 373, 442 
Farrel, 400 
Farrington, 255 
Faurd, 547 
Fauvel, 545 
Ferreri, 546 
Fish, 164 

Fish, H. M., 185, 186 
Flatau, 442 
Flemming, 384 
Fletcher, J. R., 87, 891 
Fleurens, 874 
Foster, Hal, 289 
Foucher, 351 
Fraenkel, E., 309 
Frankel, B., 266, 556, 560 
Frazier, 809 
Fredet, 448 
Freeman, 57, 58 
Freer, 82, 85, 87, 100 
Freisner, 903 
Freudenthal, 313 
Frey, 891 
Friedreich, 26, 379 
Frisco, 33, 34 
Funke, John, 785, 786 



Gallagher, 313 

Gautier, 328 

Gellius, 1023 

Gerhardt, 544, 554 

GetcheU, 512 

Gibb, 446 

Glass, 288 

Gleason, 67, 75 

Gleitsmann, 309, 313 

Gluck, 557 

Goldsmith, P. C., 99, 109 

Goldstein, 316, 772 

Goldstein, Max A., 54, 104, 

141, 289, 730 
Goodale, 44, 285, 309, 380, 

385, 386, 396 
Gottstein, 514, 661 
Gradenigo, 758, 1006, 1008, 

1021 
Gradle, 344, 758, 787, 790 
Grant, Dundas, 98 
Green, 551 

Grober, 384, 388, 390 
Grosvenor, 443 
Gruber, 268, 672 
Grunert. 815 
Grunwald, 155, 156, 181 
Guerard, 485 
Gulland, G. L., 384 
Guns, 155 

Guye, 302, 337, 538, 541 
Guyon, 373 
Guyot, 695 



H 

Habermann, 735, 761, 

1028 
Hack, 268 

Hajek, 84, 90, 161, 447, 470 
Halle, Max, 210 
Halstead, T. H., 400, 575 
Hammerschlag, 891, 1016 
Hannebert, 906 
Hansen, 322 
Harpy, 312 
Hartly, Frank, 558 
Hartman, A., 1029 
Hartz, 741 
Hasslauer, 815 
Hawley, George F., 44 
Hazletine, 105 
Heath, 44, 779, 851, 853 
Heath, Charles J., 833 
Heath, Clarence, 756 
Heinze, 309 

Helmholtz, 613, 614, 1004 
Herodotus, 1023 
Hertz, Henry J., 735 
Heuth, 853 
Heysinger, 646 
Hezener, 736 
Hibbard, 480 
Hillis, 497 
Himly, 733 
Hippocrates, 1023 
Hirsch, 235 
Hoegyes, 874 
Hollander, 306 
Hollinger, 403, 767 
Holmes, 145, 187, 634, 766, 

767 
Hoople, Heber Nelson, 34, 

35 
Hopkins, F. E., 414 
Horsley, 514, 518 
Hotz, 756, 782 
Hovell, 651, 674, 703, 714, 

772 
Hubbard, Thomas, 701 
Huizinga, J. G., 187 
Hurd, L. M., 95 



Ibsen, 1028 

Ingals, E. Fletcher, 214, 

442, 581 
Itard, 1023 



Jack, 741 

Jackson, Chevalier, 505, 
515, 555, 557, 577, 579, 
581, 586, 587, 589, 597, 
599 



Jansen, 610, 834, 853, 904 
Jarvis, 57, 58, 59 
Johnson, 313 



Kahn, Harry, 278 

Kalisko, 479 

Kanasugi, 308 

Kaposi, 287 

Katz, 735, 738 

Kauffmann, 54, 391, 403, 
408 

Keen, W. W., 568 

Keimer, 442 

Killian, Gustav, 19, 69, 84, 
90, 99, 182, 219, 220, 221. 
222, 223, 224, 251, 260, 
264, 385, 547, 578, 580, 
581, 585, 586, 587 

Kirschner, 854 

Klebs, 476 

Kleishaber, 558 

Knapp, 793, 1026 

Knight, 309 

Knoblauch, 1020 

Kobrak, 815 

Kocher, 381, 557 

Koerner, 601 

Korner, 833 

Kowalzig, 276 

Kramer, 695 

Kraus, 514, 518 

Kronlein, 979 

Kuhnt, 217 

Kuster, 218, 231 

Kyle, D. Braden, 68, 69, 
80, 154, 155, 254, 270, 
278, 307, 327, 414, 454 

Kyle, J. J., 1005 



Lack, Lambert, 302, 303 
Lake, Richard, 644, 975, 

1004 
Lancereaux, 309 
Landois, 383 
Lange, 902 

Laurentius, Andreas, 1023 
Lehart, 815 
Lemcke, 1023 
Lermoyez, 217, 339 
Leutert, 603, 754, 755, 815 
Levy, Robert, 36, 270, 313, 

315 
Lewin, G., 350 
Liebreich, 262 
Lobe, 262 
Lockard, 313 
Loeb, H. W., 162, 269 
Loeffler, 476 
lLoewy, 57 



INDEX OF AUTHORS 



1035 



Lohnberg, 314 
Louis, 44S 

Lowenberg, 637, 696 
Lubet-Barbon, 766 



M 

McAuliff, G., 649 

McBean, 1017 

McBride, 264, 333, 335, 

338, 723 
McKenzie, 434 
McKernon, J. F', 197 
MacDonald, 157 
Macdonald, Greville, 368 
Macewen, 766, 767, 770 

771, 772, 787, 811, 819 

982 
MacKenzie, E., 516 
Mackenzie, G. Hunter, 549 
Mackenzie, G. W., 872, 

881, 882 
Mackenzie, John, 317 
Mackenzie, Morrell, 414, 

530, 531, 545, 547 
Makuen, 536, 540, 541, 

543, 1032 
Malherbe, 678, 733 
Manasse, 736 
Manicatide, 479 
Martin, 481 
Maschziker, 646 
Masini, 392 
Massei, 507 

Maxwell, George T., 416 
Mayer, 77, 78, 79, 641 
Mayer, Emil, 286, 304 
Mayo, 310 
Meissner, 154, 1023 
Mendel, F., 34 
Metchnikoff, 386 
M.eyer, William, 26 
Meyjer, 448 
Michel, 447, 1028 
Miller, 470 
Milligan, A. W., 314 
Minot, 646 
Miot, 699 
Mojocchi, 328, 329 
MoU, 500 
Montain, 1028 
Monti, 480, 484 
Moorhof, 992 
Moos, 786, 1007, 1014, 

1026, 1028 
Morgani, 57, 58, 59 
Morrissy, 480 
Mosetig, 992 
Mosher, 57, 247 
Moss, Robert E., 551, 

735 
Mount-Bleyer, J., 533 
Moure, 81, 250, 344, 547 
Muller, J., 761 



Mygind, H., 306, 1023, 

1024, 1027, 1028, 1030 
Myles, 225, 238 



N 

Nagel, 197 

Neumann, 87, 88, 678, 874, 

880, 882, 884, 891, 911, 

912 
Neurenberg, 815 
Newkirk, 345 
Northrup, 477, 479, 480, 

483, 490 



O'Dwyer, 492, 493 
Oilier, 282 

Oppenheimer, 814, 815 
Orth, 309, 736 
Osier, 322, 323 
Ostrum, 223 



Packard, 380 

Page, Lafayette, 541 

Panse, 601, 990 

Parker, 352 

Passow, 990 

Patterson, 387 

Paul of iEgina, 639 

Payson, J., 547 

Pean, 559 

Pedro de Ponce, 1023 

Peltesohn, Felix, 331 

Phillips, 442 

Pierce, Norval H., 54, 141 
262, 758, 767, 848 

Piotrawski, 351 

Pischel, 72 

Pliny, 927 

PoUtzer, 616, 619, 620, 646, 
651, 656, 659, 660, 661 
667, 673, 676, 687, 694, 
696, 699, 701, 702, 724, 
725, 727, 728, 729, 730, 
733, 738, 740, 744, 746, 
747, 761, 762, 763, 766, 
767, 902, 1000, 1001, 
1002, 1003, 1006, 1008, 
1011, 1016, 1022 

Posey, W. C., 186 

Poucet, 326 

Powers, 557 

Price-Brown, 67, 69, 81 

Pritchard, Urban, 1004 

Proust, 515 

Pynchon, 127, 196, 207, 
403, 408, 415, 429, 634, 
698, 710 



Quenu, 351 



Rach, 69 

Raugi, 369 

Rebinski, 309 

Reik, 197 

Reinhard, 853 

Reininger, 155 

Reszke, Jean de, 527 

Retzius, 541 

Ribbert, 786 

Richards, 985 

Richards, George L., 344, 

441 
Richards, John, 972, 974 
Richardson, Charles, 441 
Rist, 786 
Riverias, 637 
Robertson, 310, 428 
Roe, 68, 69, 70, 77 
Roosa, St. John, 767 
Root, A. G., 524 
Rosenback, 519 
Rosenberg, 548 
Roux, 476, 481 
Rubenstein, 304 
Rumbold, T. M., 632 
Ruttin, 873, 901, 933, 936, 

938 



S 



Saissy, 646, 695, 696 

Sajous, 507 

Santorini, 601 

Schadle, 207, 255, 260, 345 

Schaus, 58, 59 

Scheibe, 735 

Schilling, 735 

Schmidt, Moritz, 266, 373, 

544, 545, 546, 547 
Schmalz, 1023, 1024 
Schnitzler, 547 
Schroetter, 505, 547, 554 
Schwalbe, 541 
Schwartze, 646, 723, 726, 

766, 767, 771, 1028 
Seifert, 350 
Seiss, 350 
Semon, Felix, 262, 414, 

514, 516, 519, 544, 546, 

553, 554, 555, 557 
Senator, 515 
Senn, 326 
Sexton, 1011 
Sexton, Samuel, 039 
Shambaugh, 613, 739. 861. 

1004 
Sheppard, 766 



1036 

Shurley, 309, 548 
Siebenmann, 601, 738 
Simon, 486 
Skilleren, 148, 269 
Sluder, Greenfield, 67, 69, 

74, 192, 430, 431, 433 
Smith, Harmon, 547, 548 
Sondermann, 127, 196 
Spencer, 758 
Stacke, 829, 833 
Stahl, 645 
Steele, J. S., 289 
Stein, O. J., 19, 262, 263, 

279, 317, 555 
Stirling, 383 
Stoerk, 574 
Stohr, 381, 382 
Strassmann, 379 
Stubbs, 343 
Stucky, 115, 164, 353 r 449, 

563, 569, 733, 767 
Suker, G. F., 187, 647, 732 
Swain, H. L., 261, 348, 549 
Sydacker, 763 



Talbot, Eugene S., 57, 

58, 59, 646 
Terry, W. J., 556 
Theisen, F., 447, 448 
Theobald, 756 
Thomer, 304 
Thompson, 265, 266, 345, 

1024 
Thorner, Max, 306 
Tilley, 230 
Tompkins, 448 
Toynbee, 726, 735, 1007, 

1023 
Trautmann, 992 



INDEX OF AUTHORS 

Trendelenburg, 57, 58 
Trousseau, 490 
Tiirck, 314 

Turner, 192, 333, 335, 338 
Turner, Logan, 164, 547, 
723 



Uffenorde, 148, 269 
Urbantschitsch, 640, 689 



Vail, 145, 226 

Valsalva, 673, 694, 701 

Verneuil, 351 

Vieussens, 155 

Villar, 370 

Virchner, 1007 

Virchow, 443, 504, 554, 646 

Voltolini, 641 

von Babes, 381 

von Bergman, 555 

von Esmarch, 276 

von Langenbeck, 276, 277, 

445 
von Stein, 926 
von Troltsch, 639, 640, 669, 

726, 761, 1023, 1024 



W 

Wade, 376 
Wale, 610 
Wales, 204 
Walsh, 474 
Walsham, 302, 381 
Watson, 67, 68, 69, 73, 268, 
558 



Waxam, F. E., 492, 493 

Weber, 1016 

Weiss, 751 

Welcker, 59, 61 

Werckmeister, 557 

Whalan, 512 

White 557 

Whiting, 767, 816, 825, 826, 

829, 836, 981 
Wild, 1023 
Wilde, 770, 824 
Williams, Watson, 20, 267, 

268, 380, 469 
Williston, 636 
Wilson, 414, 522, 596 
Wingrave, Wyatt, 786 
Woakes, 115, 449 
Wood, 164 
Wood, C. A., 187 
Wood, G. B., 387, 408, 410, 

414, 415, 416 
Woodruff, 259 
Wreden, 644 
Wright, Jonathan, 44, 127, 

380, 381, 385, 386, 391, 

396, 544, 546, 547, 815 



Yankatjer, Sidney, 90, 

715, 724, 731, 734 
Yersin, 476 



Zaufal, 603, 637, 703, 

754, 1023 
Zeim, 164 
Ziemssen, 367, 553 
Zuckerkandl, 57, 103, 351 






GENEKAL INDEX 



Abscess of brain, 799 
surgery of, 976 
peritonsillar, 404. - See also Periton- 
sillitis, 
retropharyngeal, 359 
subperiosteal mastoid, 770 
Acoumeter, Politzer's, 620 

test for hearing, 620 
Actinomycosis of nose, 325 
etiology of, 325 
pathology of, 326 
of pharynx, 326 

diagnosis of, 327 

from carcinoma, 328 
from sarcoma, 327 
from syphilis, 328 
from tuberculous disease, 
328 
electrolysis in, 328 
iodonucleoid in, 328 
potassium iodide in, 328 
symptoms of, 326 
treatment of, 328 
of tonsils, 326 
Adductor spasm of larynx, 509. See also 

Laryngismus stridulus. 
Adenectomy, anesthesia in, 340 

Richards' method of, 344 
Adenoids, 333 

aprosexia in, 337 
auditory apparatus and, 346 
aural complications in, 338 
blood in, 347 
bones and, 347 

chronic suppurative otitis media 
and, 757 
moist catarrhal otitis media 
and, 723 
club foot and, 347 
deaf -mutism and, 1030, 1031 
diffused hypertrophic laryngitis and, 

465, 467 
diagnosis of, 338 

from granulomata, syphilitic, 
339 
tuberculous, 339 
from tumors, fibrous, 338 
malignant, 339 
epipharyngeal catarrh in, 337 

inflammation and, 345 
in epipharynx, 337 



Adenoids, epithelium in, 334 
etiology of, 333 
Eustachian tubes and, 346 
"face," 339, 345 
fibrous tissues in, 335 
forceps, Brandegee's, 339, 341 
"Gothic" arch and, 345 
hard palate and, 345 
hearing in, defective, 337, 633, 634 
heredity and, 333 
lymphoid tissues in, 335 
membrana tympani in, 346 
mentality in, 337 
mouth breathing in, 337 
nasal inflammation and, 115 
operations for, Ballenger's, 339 

Boeckmann-Stubbs' curette in, 

341 
Brandegee's adenoid forceps in, 

339, 341 
Ferguson-Pynchon's mouthgag 

in, 340 
Meyer's ring curette in, 344, 349 
pharyngeal scissors in, 347 
position of patient in, 340, 342 
Pynchon-Golding-Bird's curette 

in, 344 
Quinlan's forceps in, 344 
Shutz's adenotome in, 344 
Stubbs', 343 
otitis media and, 338 
pathology of, 333 
pharyngeal, 333 
"pigeon chest" and, 347 
prognosis of, 339 
respiration in, 336, 343, 344 
sequelae of, 345 
singing voice and, 526 
speech in, defective, 337, 539 
suppurative otitis media and, 346 
symptoms of, 336, 337 
teeth and, 345 
Thornwaldt's disease in, 347 
treatment of, 339 
tubal catarrh and, 684, 685 
vegetations, 333 
Adenoma of nose, 278 
Adenopathy, diphtheria and, 485 
Adentome, La Force, 339 
Adhesive processes in middle ear, 724 
Aditus ad antrum, obstruction of, 767, 
779, 780 
relations of, 609 

(1037) 



1038 



GENERAL INDEX 



Aditus ad antrum, relations of, to facial 

nerve, 834 
Adrenalin in epistaxis, 285 
Agglutination methods for removal of 

foreign bodies in ear, 637, 638 
Agraphia, amnesic, 1020 
Air pressure, negative, treatment of 

sinuitis by, 196 
Akinesis of pharynx, 365 
Alae nasi, collapse of, 302 

etiology of, 302 
operation for, Lack's, 303 

Walsham's, 302 
symptoms of, 302 
treatment of, 302 
Albuminuria in diphtheria, 482, 485 % 
diphtheria antitoxin and, 489 
hemorrhagic laryngitis and, 472 
Alcohol, 51 

diffused hypertrophic laryngitis and, 

465, 467 
hyperacuteness of hearing and, 1016 
in hyperemia of labyrinth, 1000 
injections for hyperesthetic rhinitis, 

263 
tinnitus aurium and, 720, 727 
treatment of chronic suppurative 
otitis media, 760, 781 
of diphtheria, 468 
Alcoholism, arteriosclerosis of labyrinth 
and, 1005 
deaf-mutism and, 1025 
Alimentary canal in diphtheria, 480 
Allen's nasal speculum, 97 
Allport's bone-crushing forceps, 858 
divulsion forceps, 841 
mallet, 828 

mastoid retractor, 858 
Alveolar operation upon maxillary sinus, 
238 
process, lavage of maxillary sinus 
through, 194 
American method of inflation of tympanic 

cavity, 700 
Amnesic agraphia, 1020 

aphasia, 1020 
Amusia, 1020 
Amyl nitrite, hyperemia of labyrinth 

from, 1000 
Anastomosis of facial nerve with hypo- 
glossal nerve, 995-999 
of ' hypoglossal nerve with facial 
nerve, 995-999 
Andrews' cannula, 195 
Anemia of labyrinth, 1001 

nose and, 28 
Anesthesia in adenectomy, 340 

cocaine, in indirect laryngoscopy, 
549 
in operations on tonsils, 418, 
420, 429 
for direct laryngoscopy, 587 
nitrous oxide, in tonsillotomy, 436 
of pharynx, 364 
rectal, for laryngofissure, 563 



Anesthesia in submucous resection of 
nasal septum, 82 
in tonsillectomy, 417 
for tracheoscopy, 581 
for upper tracheobronchoscopy, 589 
Anesthetic leprosy, 323 
Aneurysm of arch of aorta, laryngeal 
paralysis and, 517, 520 
diagnosis of, from retropharyngeal 

abscess, 359 
laryngeal paralysis and, 522 
of subclavian, laryngeal paralysis 
and, 517, 521 
Aneurysmal cough in laryngeal paralysis, 

519 
Angina in diphtheria, 482 

epiglottidea anterior, 447 
lacunaris of pharyngeal tonsil, 331 
laryngis, diagnosis of, from chronic 

laryngitis, 474 
pseudomembranous, 400 
Vincent's, 400 

diagnosis of, 401 
etiology of, 400 
pathology of, 400 
prognosis of, 401 
symptoms of, 401 
treatment of, 401 
Angioma of auricle, 650 
diagnosis of, 651 

from othematoma, 651 
electrolysis for, 651 
Paquelin's cautery for, 651 
symptoms of, 650 
treatment of, 651 
of nose, 278 

galvanocautery for, 279 
symptoms of, 278 
treatment of, 278 
of pharynx, 373 

electrolysis in, 373 
treatment of, 373 
of tonsil, 442 

electrolysis in, 442 
Angioneurotic paralysis of auditory nerve, 

1015 
Ankylosis of ossicles in adhesive pro- 
cesses of middle ear, 728, 729 
in deaf-mutism, 1028 
defective hearing from, 631 
tuberculous, of arytenoid cartilages, 
505 
Annulus tympanicus, 610 

relation of, to facial nerve, 835 
Anosmia, 253 

obstruction of olfactory fissure and, 

253 
in sinuitis, 186 
Antrum chisels, Corwin's, 227 

of Highmore. See Sinus, maxillary. 
Antrum saw, Vail's, 226 
Aphasia, amnesic, 1020 
Aphonia in acute catarrhal laryngitis, 
449, 453 
in laryngeal diphtheria, 483 



GENERAL INDEX 



1039 



Aphonia in larjoigeal paralysis, 516, 519, 
521 
in membranous laryngitis, 460 
in papilloma of larynx, 547 
spastica, 509 

in tuberculosis of larynx, 311 
Apoplexy, laryngeal, 511 
etiology of, 512 
neurasthenia and, 512 
symptoms of, 512 
treatment of, 512 
Aprosexia in adenoids, 33? 

defects of speech and, 538, 539 
in fibroma of pharynx, 370 
Aquaeductus vestibuli in deaf-mutism, 

1028 
Aquiline or hump nose, 295 
Arch, Gothic, 57 
Arsenic paste for lupus, 305, 306 
Arteriosclerosis, epistaxis and, 285 

of labyrinth, 1005 
Arthritis, catarrhal laryngitis and, 450 
Articulation in deaf-mutism, 1029 
Arytenoid cartilages, tuberculous anky- 
losis of, 505 
"Ascending croup," 484 
Asch-Mayer's operation for deviation of 

nasal septum, 77, 78, 79 
Asch's septum forceps, 78 
Aspergillus niger, 664 
Asphyxia in edema of larynx, 462 
in laryngeal diphtheria, 483 
in operations for laryngeal carci- 
noma, 575 
Asthenopia in disease of sinuses, 205 

due to enlargement of middle tur- 
binated bone, 35 
Asthma, miller's, 455, 509. See also 
Laryngismus stridulus, 
of nasal origin, 267 
in obstructive deviations of nasal 

septum, 65 
rachiticum, 509. See also Laryn- 
gismus stridulus, 
thymic, 509. See also Laryngismus 
stridulus. 
Ataxia, locomotor, laryngeal paralysis 

and, 521 
Atrium of ear, outer wall of, removal of, 
in radical mastoid operation, 
838 
suppuration of, 781 
Atrophic laryngitis, 471 

rhinitis, 154 
Attic of ear, caries of, 773 

divisions of, 611, 612 

external, acute inflammation of, 

717, 718 
outer wall of, removal of, in 
radical mastoid operation, 838 
suppuration of, 607, 678, 781, 
782 
of nose, 254 
Auditory apparatus, functional tests of, 
618 



Auricle, angioma of, 650 

chondritis of, 601 

cysts of, 652 

dermatitis of, 656 

epithelioma of, 652 

fibroma of, 651 

herpes of, 655 

zoster of, 656 

lesions of, defective hearing from, 630 

malformations of, 645 

neoplasms of, 648 

nodular enlargements on, 652 

perichondritis of, 601, 654 

sarcoma of, 652 
Aurophone in hyperostosis of bony cap- 
sule of labyrinth, 741 
Auscultation, aural, 712 

of tympanic cavity, 696, 697, 702 
"Aussatz," 321. See Leprosy. 
Autophony, 689 

in chronic moist catarrhal otitis 
media, 720 



B 



Bacilli in upper respiratory tract, il3 
Bacillus leprae, 321 
mallei, 323 

pyocyaneus in membranous laryn- 
gitis, 460 
of rhinoscleroma, 287 
Bacteremia, thrombosis of lateral sinus 

and, 814, 815 
Bacteriological diphtheria, 480 
Ballance flap method in radical mastoid 
operation, 840, 854 
incision in radical mastoid operation, 
841, 843 
Ballenger-Foster septum speculum, 97 
Ballenger's complete operation on tonsil 
with right-angle knife and ecraseur, 
417 
curette, 246 
ethmoid knives, 246 
mastoid periosteal elevator, 826 
modification of radical mastoid opera- 
tion, 848 
mucosa knife, 96 

swivel knife, 105 
nasal septum clamp, 293 
operation for adenoids, 339 

for complete exenteration of 
ethmoidal cells and middle 
turbinal, 242 
upon ethmoidal sinuses, 239. 242 
for fibromata of pharynx. 372 
intranasal, for aquiline or hump 

nose, 296 
upon frontal sinus, 207 
for long or drooping nose, 297 
for peritonsillitis, 407 
for removal of ethmoidal cells. 

239 
upon sphenoidal sinuses, 251 



1040 



GENERAL INDEX 



Ballenger's operation on tonsils with 
scalpel, 423 
for twisted or crooked nose, 291, 
292, 293 
reverse chisel, 297 
right-angle knife, 417 
septum gouge, 96 
swivel cartilage knife, 96 

turbinotome, 146 
tonsil ecraseur, 421 
forceps, 418 
knife, 424 
syringe, 441 
turbinal knives, 240 
turbinotome, 150, 152 
vulsellum forceps, 418 
Bane-Allport gauze packer, 758 
Barany's fixation apparatus in vestibular 
nystagmus, 903 
noise apparatus, 627 
Beck's double osteoplastic operation 
upon frontal sinus, 219 
mercury massage, 43 
paraffin syringe, 299 
Beckmann's serrated scissors, 145 
Beck-West method of enucleation of 

tonsils, 426 
Bellocq's postnasal tampon cannula, 145 
Benzoin, compound tincture of, in treat- 
ment of chronic suppurative otitis 
media, 782 
Bezold-Edelmann tuning forks, 617 
Bezold's mastoiditis, 857, 859, 860 
Bier's hyperemic treatment, 127 
indications for, 128 
in mastoiditis, 768, 769 
technique of, 128 
Bing's test for hearing, 628 
Binnafont method of Eustachian cath- 
eterization, 695, 696 
Birmingham nasal douche, 274 
Bishop's trephine, 229 
Bismuth, subnitrate of, powder, 50 
Black diphtheria, 285, 483 
Blennorrhea, Stoerk's, 286, 468 
Blood count in thrombosis of lateral 
sinus, 814 
cultures in thrombosis of lateral 

sinus, 813 
spitting of, 472 
Boeckmann-Stubbs' curette, 341 
Boetcher's tonsil hemostat, 422 
Bone marrow in diphtheria, 480 
Bony capsule of labyrinth, hyperplasia of, 

735 
Boric acid powder in treatment of chronic 

suppurative otitis media, 781 
Bosworth's operation for deviation of 
nasal septum, 70, 71, 72 
saw,- 71 
Bougies in obstruction of Eustachian 

tube, 689, 690, 731 
Bourguet's labyrinth operation, 968 
Boyce's position for tracheoscopy, 581 
Bradycardia in diphtheria, 481 



otitis media 



Brain, abscess of, 799 

acute suppurative 

and, 748 
cholesteatoma and, 763 
chronic otorrhea and, 752, 805 
exploration of, indications for, 

805 
head pain in, 805 
incisions for, 977 
infection of tympanic cavity 

and, 608 
irritability in, 805 
prognosis of, 806 
stages of, 801, 802, 804 
stupor in, 805, 
surgery of, 976 

drainage through squamous 
plate in, 978 
through tegmen tym- 
pani in, 976 
symptoms of, 801 
tegmen tympani in, perforation 

of, 801 
treatment of, 806 
vertigo in, 805 * 
diseases of, deaf-mutism and, 1026 
tumor of, deafness from, 1021 
laryngeal paralysis and, 521 
paralysis from, 1021 
spasm of pharynx and, 367 
Brandegee's adenoid forceps, 339, 341 
"Braune, hautige," 459 
Breathing, inferior costal type of, 528 

methods of, 527 
Bright 's disease, edema of larynx and, 462 
Bronchi, diphtheria of, 484 

foreign bodies in, 577 
Bronchial diphtheria, 484 

syncope, 511 
Bronchitis, diphtheria and, 486, 487 
Bronchopneumonia, diphtheria and, 487 
Bronchoscopy, 581. See also Tracheos- 
copy. 
Brophy vaporizer, 589 
Buchanan's anesthetizing dosimetric at- 
tachment, 590 
Bulb, jugular, surgery of, 989, 990, 991 
Bulbar paralysis of. pharynx, 365, 366 
Bulla ethmoidalis, obstruction of nose 

due to, 119 
Buttles-Pynchon inhaler, 686 



"Cadaveric" position of vocal cords in 

laryngeal paralysis, 519, 521 
Caisson workers, hemorrhage into laby- 

rinth in, 1001 
Calomel in acute laryngitis in children, 
457 
fumigations in membranous laryn- 
gitis, 462 
Calcareous deposits in membrana tym- 
pani, 679, 788 






GENERAL INDEX 



1041 



Calculus of tonsils, 403 

Caldwell-Luc's operation upon maxillary 

sinus, 231 
Caloric nystagmus, 874 

reactions in diffuse latent suppura- 
tive labyrinthitis, 950 
test in acute diffuse serous laby- 
rinthitis, 937 
of vestibular apparatus, 881 
Camphoroxol, treatment of chronic sup- 
purative otitis media with, 782 
Canal, frontonasal, 191, 192 
Canaliculus carototympanici, 610 
Cancer. See Carcinoma. 
Canfield-Ballenger's antrum operation 

upon maxillary sinus, 233 
Cannula, Andrews', 195 

Bellocq's postnasal tampon, 145 
Well's trocar, 229 
Capsule, bony, of labyrinth, otosclerosis 
of, 735 
hyperplasia of, 735 
Capsulitis labyrinthii, 735 
Carcinoma, inoperable, of upper respira- 
tory tract, 377 
laryngeal, 533, 553 
age and, 554 
cough in, 555 
diagnosis of, 557 
early, 553 

from benign neoplasms, 557 
from laryngitis, chronic, 557 
syphilitic, 557 
tuberculous, 557 
from perichondritis, 557 

from tuberculosis of larynx, 

312 
microscopic, 556 
dysphagia in, 555- 
etiology of, 554 
heredity and, 554 
hoarseness in, 553, 555 
laryngoscopy in, 556 
lymphatic glands of neck in, 

involvement of, 555 
operations for, asphyxia in, 
575 
cardiac reflexes in, 575 
inspiration pneumonia and, 

575 
rectal alimentation and, 575 
shock in, 574 
sudden death after, 574 
voice and, 575 
pain in, 553, 555 
pathology of, 555 
prognosis of, 557, 558, 559 
recurrence of, after operation, 

576 
sex and, 554 
social standing and, 554 
symptoms of, 555 
tobacco and, 554 
treatment of, 558, 576 
of nose, 281 
66 



Carcinoma of nose, diagnosis of, 281 
prognosis of, 281 
treatment of, 281 
of pharynx, diagnosis of, from actino- 
mycosis of pharynx, 328 
of subglottic region, diagnosis of, 

from chronic laryngitis, 473 
of tonsils, 444 

diagnosis of, from sarcoma, 445 
symptoms of, 444 
treatment of, 445 
Cardiac infection in membranous laryn- 
gitis, 461 
paralysis in diphtheria, 486 
reflexes in operations for laryngeal 
carcinoma, 575 
Caries of attic of£ear, 773 

of ossicles, defective hearing from, 

631 
of teeth, sinuitis and, 177 
Carotid artery, external, excision of, 377 
Carter's nasal splint, 292 
Cartilage knife, Ballenger's swivel, 96 
septal, reformation of, 101, 102 
removal of, 91 
Cartilaginous deviations of nasal septum, 
60 
meatus of ear, collapse of, defective 
hearing from, 630 
Casselberry's operation for amputation 
of uvula, 358 
position for feeding in intubation, 
497, 498 
Catarrh, epipharyngeal, in adenoids, 337 

tubal, 684 
Catarrhal diphtheria, 480 

lingual tonsillitis, acute, 349 
otitis media, acute, 703 

chronic moist, 718 
pharyngitis, simple acute, 352 
sinuitis, treatment of, 190 
Catching cold, 396, 449, 450 
Catheterization, Eustachian, 695 
diagnostic value of, 698 
methods of, 695, 696 
Binnafont, 695, 696 
Kramer, 695, 696 
Lowenberg, 696 
through mouth, 698 
through opposite nasal 
cavity, 697 
therapeutic value of, 698 
inflation of tympanic cavity by, 695 
Caustics, chemical, 53 
Cauterization, submucous, for chronic 

rhinitis, 141 
Cautery for soft hypertrophies of nasal 

septum, 70 
Cavernous sinus, thrombosis of, SIT 
Cavum tympani. See Tympanic cavity. 
Cells of Kirschner, 854 
Cellulitis, cervical, tonsillectomy and, 392 

ethmoid operation and, 247 
Central paralysis of pharynx, 366 
Cerebellar abscess, surgery of, 9S2 



1042 



GENERAL INDEX 



Cerebellar nystagmus, 872 
Cerebral abscess, surgery of, 976 

hemorrhage, accessory nasal sinuses 

and, 187 
paralysis in diphtheria, 479 
Cerebrospinal fluid in middle ear, 670 

rhinorrhea, 265, 266 
Cerumen, impacted, 642 
diagnosis of, 643 
etiology of, 642 
nervous cough from, 511 
prognosis of, 643 
symptoms of, 642 
treatment of, 643, 644 
Weber's test for, 643 
inspissated, defective hearing from, 
630 
Ceruminous plugs, dizziness from, 643 

improper cleansing of ear and, 
642 
Cervical cellulitis, tonsillectomy and, 392 
glands, removal of, 361, 362 
suppuration of, 398 
tuberculous, 316 
Chaleway's spokeshave, 72 
Cheyne-Stokes respiration in leptomenin- 
gitis, 795 
Chilblain, 657 

Child-crowing, 509. See also Laryngis- 
mus stridulus. 
Chimani-Moss test for simulated deaf- 
ness, 1014 
Chisel, Ballenger's reverse, 297 

Corwin's antrum, 227 
Choanse, adhesions around, 371 
Cholesteatoma, 761 

abscess of brain and, 763 
defective hearing from, 630 
diagnosis of, 763 
etiology of, 761 
extradural abscess and, 792 
primary, 761 
-prognosis of, 763 
secondary, 761 
sequelae of, 765 
sinus thrombosis and, 763 
symptoms of, 762 
treatment of, 763 
Cholesterin in chronic lacunar tonsillitis, 

402 
Chondritis of auricle, 601 
Chondroma of subglottic space, 546 
Chorditis nodosa, 469, 498, 544, 545 
etiology of, 470 
massage for, 471 
pathology of, 470 
prognosis of, 470 
symptoms of, 470 
treatment of, 471 
voice in, 470 
tuberosa, 469 

vocalis hypertrophica inferior, 468 
Chorea, laryngeal, 510 
Chromic acid method, Goldstein's, of 
submucous cauterizatiou, 141 



Cigarette drain, 362, 378 

Circumscribed labyrinthitis, nystagmus 

in, 904 
Cleft palate, singing voice and, 532 
Clergyman's sore throat, 353, 531. See 

also Pharyngitis, chronic. 
Club foot, adenoids and, 347 
Cocaine anesthesia in indirect laryngos- 
copy, 549 
in operations on tonsils, 418, 
420, 429 
in epistaxis, 285 
in tuberculosis of larynx, 313 
function of, 613 
hyperostosis of, 739 
Codeine for cough in acute catarrhal 
laryngitis, 455 
laryngitis in children", 458 
in tuberculosis of larynx, 312 
Cold, dermatitis of auricle due to, 657 
Collapse of alse nasi, 302 
Colloid degeneration of nose, 287 
Collodion dressing, Pischel's, 144 
Compsomyia macellaria, 636 
Concussion of labyrinth, 1010 
Condyloma of epiglottis, 319 
Consanguinity, deaf-mutism and, 1025 
Convulsions in abscess of brain, 803 

in acute suppurative otitis media in 
children, 751 
Cooper-Hewitt light for tuberculosis of 

larynx, 313 
Cooper's operation upon maxillary sinus, 

230 
Corona veneris, 33 
Corti's cells, 612, 613 
Corwin's antrum chisels, 227 

operation upon maxillary sinus, 227 
Coryza, acute, 130 
edematosa, 264 
pus in, 160 
sinuitis and, 188 
syphilitic, 33 
Cough in acute catarrhal laryngitis, 453 
laryngitis in children, 455, 456 
aneurysmal, in laryngeal paralysis, 

519 
in atrophic laryngitis, 471 
in chronic pharyngitis, 354 
in diphtheritic paralysis, 486 
in discrete hypertrophic laryngitis, 

468 
from foreign body in respiratory 

passages, 577 
in hyperkeratosis of tonsil, 409 
in laryngeal carcinoma, 555 
diphtheria, 483 
paralysis, 519 
in membranous laryngitis, 460 
nervous, 511 

in papilloma of tonsil, 442 
in phlegmonous laryngitis, 458 
reflex, in elongated uvula, 356 

in papillomata of larynx, 368 
spasmodic laryngeal, 510 



GENERAL INDEX 



1043 



Cough in syphilitic stenosis of larynx, 503 
Count erirritation, 122 
Cretinism, nasal deformity in, 298 
Cricoid cartilage, perichondritis of, 457 
Cristae ampullares, 870, 876 
Croup, 459. See also Laryngitis, mem- 
branous, 
"ascending," 484 

diphtheritic, 483. See also Diph- 
theria, laryngeal, 
false, 455, 509. See also Laryn- 
gismus stridulus, 
idiopathic membranous, 459 
membranous, 483. See also Diph- 
theria, laryngeal, 
pseudomembranous, 459 

diagnosis of, from acute laryn- 
gitis in children, 457 
silent, 460 

true, 483. See also Diphtheria, 
laryngeal. 
Croupous inflammation of external audi- 
tory meatus, 661 
laryngitis, 459 
Cryptic tonsillitis, 396 
Curettage in chronic suppurative otitis 
media, 760 
of tympanic cavity, dangers of, 836 
Curette, Ballenger's, 244 
Cyanotic congestion, atrophic rhinitis 
and, 154 
engorgement, atrophic rhinitis due 
to, 155 
Cystoma of pharynx, 369 

of tonsils, 443 
Cysts of auricle, 652 

of subglottic space, 546 



Deaf-mutism, 537, 1023 
adenoids and, 1030, 1031 
age and, 1026 
alcoholism and, 1025 
aquseductus vestibuli in, 1028 
ankylosis of ossicles in, 1028 
articulation in, 1029 
brain diseases and, 1026 
classification of, 1024 
consanguinity and, 1025 
deafness in, 1028 
death rate in, 1026 
diagnosis of, 1031 
epilepsy and, 1025 
etiology of, 1024 
Eustachian tubes in, 1028 
hearing in, 1028 
hemophilia and, 1025 
heredity and, 1025 
idiocy and, 1031 
infectious diseases and, 1026 
labyrinth in, 1028 
lungs in, 1030 
mental training in, 542 



Deaf-mutism, otorrhcea in, 1030 
pathology of, 1027 
prognosis of, 1031 
sequelae of, 1030 
smallpox and, 1027 
speech in, 542, 1029 
symptoms of, 1028 
syphilis and, 1025 
testing for, 1029 

for "islands of hearing" in, 
617 
tinnitus in, 1030 
treatment of, 1031, 1032 
tuberculosis and, 1030 
voice in, 1029 
Deafness in acute diffuse suppurative 
manifest labyrinthitis, 942 
suppurative otitis media and, 
_ 745, 747 
adhesive processes in middle ear 

and, 727 
in arteriosclerosis of labyrinth, 1006 
chronic moist catarrhal ot itis media 

and, 718, 719 
in concussion of labyrinth, 1011 
diffuse latent suppurative labyrinth- 
itis, 949 
hysterical, diagnosis of, from arterio- 
sclerosis of labyrinth, 1006 
islands of, 739 
leukemic, 1006 
locomotor ataxia and, 1022 
in Meniere's disease, 1002 
occupation, 1012 
perforation of membrana tympani 

and, 673 
physiological law of, 607 
simulated, 1013 

tests for, 1013, 1014 

Chimani-Moos, 1014 
Erhard, 1014 
stethoscope, 1014 
in syphilis of internal ear, 1007, 1008 
syphilitic condyloma of external ear 

and, 321 
tumor of brain and, 1021 
"Decapitation" of tonsils, 392 
Defective hearing, 630 
Defects of speech, 536 
Deformities of nose, correction of, 289 
Delstanche's masseur, 40, 42, 682, 717 
rarefacteur, 1005 
ring knife, 821 
Dementia, othematoma and, 64S 
Denker's operation upon maxillary sinus, 

233 
Dermatitis of auricle, 656 
due to cold, 657 

etiology of. 657 
symptoms of, 057 
treatment of, 657 
treatment of, tioti 
congelationis auricula, 657 
Deviations of nasal septum, 57 
De Vilbiss' spray tubes, 44 



1044 



GENERAL INDEX 



Diabetes, edema of larynx and, 462 

hemorrhage into labyrinth in, 1001 
hemorrhagic laryngitis and, 472 
otitis media and, 710, 744 
Diaphragmatic paralysis in diphtheria, 

486 
Diffused inflammation of external audi- 
tory meatus, 659 
laryngitis, chronic, 466 
"Dip" of postsuperior wall in simple 

acute mastoiditis, 766 
Diphtheria, 474 

adenopathy and, 485 
age and, 475 
albuminuria in, 485 
alimentary canal in, 480 
angina in, 482 

antitoxin, administration of, 489 
albuminuria and, 489 
dosage of, 489 

effect of, on pseudomembrane, 
489 
on temperature, 489 
immunization by, 488 
indications for, 489 
injection of, place of, 489 
in laryngeal cases, 489 
paralysis and, 489 
value of, 488 
bacteriology of, 476 
black, 285, 483 _ 
blood-pressure in, 481 
bone marrow in, 480 
bradycardia in, 481 
bronchial, 484 
bronchitis and, 486, 487 
bronchopneumonia and, 487 
catarrhal, 480 
complications of, 485 
diagnosis of, 485 

bacteriological, 477 
from acute lacunar tonsillitis, 
398 
laryngitis in children, 
456 
from membranous laryngitis, 
461 
of ear, 484 
epistaxis and, 284 
of esophagus, 485 
etiology of, 474 
fruste, 480 
gangrenous, 479, 481 
glycosuria and, 480 
heart in, 479, 486 
histopathology of, 478 
hyperemia of labyrinth and, 1000 
hyperleukocytosis in, 486 
infection in, mixed, 478 
modes of, 475, 476 
intubation in, 485, 486, 492 
kidneys in, 480 
Klebs-Loeffler bacilli in, 478 
laryngeal, 483 

antitoxin in, 489 



Diphtheria, laryngeal, aphonia in, 483 
asphyxia in, 483 
cough in, 483 
hoarseness in, 483 
invasion in, 483 
mixed, 484 

paralysis and, 515, 520 
phlegmonous, 484 
respiration in, 483 
septic, 484 
spasm in, 483 
stenosis of larynx in, 483 
voice in, 483 
"le con proconsulair " symptom in, 

485 
lesions in spinal cord due to, 479 
liver in, 480 
lungs in, 479 
lymphatic glands in, 480 
mixed, 481 
mucous membrane in, sloughing of, 

479 
muscles in, 480 
nasal, 481, 482, 485 
Neisser-Ernst bodies in, 477 
nervous system in, 479, 486 
of nose, 482 
obstruction of Eustachian tube and, 

689 
pancreas in, 480 
paralysis in, cardiac, 486 
cerebral, 479 
cough in, 486 
diaphragmatic, 486 
postdiphtheritic, 486 
diffused, 486 
general, 486 
vagus, 486 
of velum palati, 486 
phlegmonous, 481 
polar granules in, 477 
prognosis of, 485 
prophylaxis of, 487 
pseudodiphtheria bacilli in, 478 
pseudomembrane in, 478 , 
"pseudotabes" and, 486 
pulse in, 481 
race and, 474 
septic, 481 
septicemia and, 481 
sequelae of, 485 
skin in, 486 
spleen in, 480 
of stomach, 485 
stricture of external auditory meatus 

and, 663 
symptomatology of, 481 
tachycardia in, 481 
temperature in, 481 
thymus gland in, 476 • 
of trachea, 484, 578 
tracheotomy in, 486, 490 
treatment of, 485 
alcohol, 488 
antitoxin, 488 



GENERAL INDEX 



1045 



Diphtheria, treatment of, general, 488 
local, 488 
surgical, 490 
types of, 480 
urine in, 485 
Diphtheritic croup, 483 
laryngitis, 459 
paralysis of pharynx, 366 
"pseudotabes," 486 
Diplacusis, 1017 

acoustica in concussion of labyrinth, 

1011 
binauralis or disharmonica, 615 
Direct laryngoscopy, 546, 549, 587 
Discrete hypertrophic laryngitis, 468 
Disharmony, destruction, in acute diffuse 
serous labyrinthitis, 938 
suppurative manifest 
labyrinthitis, 941 
stimulation in acute diffuse suppura- 
tive manifest labyrinthitis, 941 
Dislocated nose, 294 
Diverticulum of hypopharynx, 595 
Dizziness from ceruminous plugs, 643 
in hyperesthetic rhinitis, 255 
from irrigation of ear, 644 
in Meniere's disease, 1002 
in meningitis serosa, 790 
in obstructive deviations of nasal 

septum, 63 
in syphilis of internal ear, 1007 
Dobel's solution, 549 
Douche, Birmingham nasal, 274 
Dry catarrh of middle ear, 724 
chronic rhinitis, 154 
gauze treatment of chronic suppura- 
tive otitis media, 781 
Dunbar's serum in treatment of hyper- 
esthetic rhinitis, 262 
Dyscrasias, constitutional, acute rhinitis 

complicating, 130 
Dysphagia in carcinoma of larynx, 555 
in laryngeal carcinoma, 555 

in paralysis of pharynx complicating 

facial paralysis, 367 
in tuberculosis of larynx, 308 
Dyspnea in acute infectious epiglottitis, 
448 
phlegmonous laryngitis, 458 
in atrophic laryngitis, 471 
in discrete hypertrophic laryngitis, 

468, 469 
in edema of larynx, 463 
in epiglottitis, 448, 449 
in laryngeal paralysis, 519, 521, 522 
in membranous laryngitis, 460 
in miasmatic epiglottitis, 449 
in papilloma of larynx, 547, 548 
in syphilitic stenosis of larynx, 503 
in tuberculosis of larynx, 312 

E 

Ear, auricle of. See Auricle, 
ceruminous plugs in, 642 



Ear, clinical anatomy of, 601 
diphtheria of, 484 
external, 601 

clinical anatomy of, 601 
eczema of, 665, 666 
syphilis of, 320, 321 
foreign bodies in, 635, 636 
general medicine and, 26 
improper cleansing of, ceruminous 

plugs and, 660 
internal, neoplasms of, 1021 

syphilis of, 1007 
irrigation of, dizziness from, 644 
middle, actinomycosis of, 328, 329 
adhesive processes in, 603, 
724 
ankylosis of ossicles in, 

728, 729 
course of, 727 
deafness from, 727 
diagnosis of, 728 
etiology of, 725 
hearing in, 727 
hyperesthesia acous- 
tica in, 727 
incision of membrana 

tympani in, 678 
inflation of tympanic 

cavity in, 728, 729 
massage in, 730 
membrana tympani in, 

726 
paracusis Willisii in, 

727 
pathology of, 725 
Rhine test in, 728 
symptoms of, 728 
tinnitus in, 727 
treatment of, 729 
affections of, defective hearing 

from, 630 
arteries of, 610 
catarrh of, chronic moist, 718, 

725 
cerebrospinal fluid in, 670 
clinical anatomy of, 602 
disease of, Eustachian tube and, 

683 
dry catarrh of, 724 
foreign bodies in, 641 
proliferous inflammation of, 

724 _ 
sclerosis of, 724 

suppuration of, incision of mem- 
brana tympani in, 678, 679 
tuberculosis of, 314 
muscles of, intrinsic, 612 
ossicles of, 607 
physiology of, 610 
relations of, to nose and throat, 31 
in tabes dorsalis, 32 
Eardrjm. See Membrana tympani. 
Eczema of external ear, acute, Q>65 
chronic. 6i}C>, 667 
subacute. 6^6 



1046 



GENERAL INDEX 



Edema, angioneurotic, acute, diagnosis of, 

from acute infectious epiglottitis, 

448 

v of bronchial mucous membrane in 

membranous laryngitis, 461 

chronic, in syphilitic stenosis of 

larynx, 503 
glottidis, 462 
of larynx, 462 

asphyxia in, 462 
voice in, 463 
of nose, acute circumscribed, 264 
of uvula, 355 
Edlemann-Bezold forks, 739 
Elastic uvula, 357 
Electrocautery, 43 

in angioma of nose, 279 
in chronic phaiyngitis, 355 

rhinitis, 139 
in epistaxis, 285 
in fibroma of pharynx, 372 
in hyperkeratosis of tonsil, 413 
in hypertrophic rhinitis, 144 
incision of membrana tympani with, 

680 
in lingual varix, 351 
in lupus of nose, 306 
for neoplasms of subglottic space, 546 
for removal of foreign bodies in ear, 
641 
Electrolysis in actinomycosis of pharynx, 
328 
in angioma of auricle, 651 
of pharynx, 373 
of tonsil, 441 
in obstruction of Eustachian tube, 

689 
in pachydermia laryngis, 500 
in papilloma of phaiynx, 368 
Elephantiasis graecorum, 321 
Elongation of uvula, 356 
Elevators, Hajek-Ballenger mucoperi- 
chondria, 96 
for submucous resection of nasal 
septum, 85, 86, 87, 96 
Embolic abscesses, thrombosis of ear and, 

810 
Emphysema of orbital tissues, ethmoid 

operation and, 248 
Empyema of accessory sinuses, 169 
nasal secretion in, 31 
of ethmoidal cells, 148 
in sinuitis, 169 
Encephalitis, hyperemia of labyrinth and, 

1000 
Encephaloscope, Whiting's, 981 
Enchondrosis of larjugeal cartilages, 
diagnosis of, from chronic laryngitis, 
473 
Endocarditis, infection through tonsils 

and, 382, 391, 398 
Endolaryngeal operations, 560 
Endolymph, 613 

Enteritis, metastatic, in thrombosis of 
lateral sinus, 812 



Enucleation of tonsils, Beck- West method 

of, 426 
Epiglottis, condylomata of, 319 

diseases of, inflammatory, 447 
Epiglottitis, dyspnea in, 448, 449 
infectious, acute, 447 

diagnosis of, 448 

from acute angioneu- 
rotic edema, 448 
dyspnea in, 448 
etiology of, 447 
pathology of, 448 
prognosis of, 448 
Staphylococcus albus in, 

448 
Streptococcus aureus in, 

448 
symptoms of, 448 
syphilis and, 448 
tracheotomy in, 449 
treatment of, 448 
tuberculosis and, 448 
miasmatic, 449 

dyspnea in, 449 
etiology of, 449 
symptoms of, 449 
Epilepsy, deaf-mutism and, 1025 

of nasal origin, 267 
Epipharyngeal catarrh in adenoids, 337 
diseases, acute catarrhal otitis media 

and, 708 
"dropping," 65 

inflammation, adenoids and, 345 
space, variations in, 344, 345 
tonsils, 349 
Epipharyngitis, 467, 510 

in acute laryngitis in children, 455 
chronic suppurative otitis media and. 

758 
curettage of Eustachian tube and, 

838, 839 
obstruction of Eustachian tube and, 

689 
tubal catarrh and, 684 
Epipharynx, adenoids in, 337 
adhesions in, 363 
affections of, defective hearing from, 

633, 634 
crusts in, significance of, 168, 173 
diseases of, 331 
osteoma of, 280 
tumors of, fibrous, 338 
Epistaxis, 284 

adrenalin in, 285 
arteriosclerosis and, 285 
cocaine in, 285 

deviation of nasal septum and, 66 
diphtheria and, 284 
electrocautery in, 285 
etiology of, 284 
hemophilia and, 285 
treatment of, 285 
typhoid and, 284 
Epithelioma of auricle, 652 
Equinia maliasmus, 323 



GENERAL INDEX 



1047 



Erectile tissue of nose, 18 

tumors of pharynx, 373 
Erhard test for simulated deafness, 1014 
Erysipelas, acute phlegmonous laryngitis 
and, 458 
of face, cerebellar nystagmus and, 

873 
of larynx, 463 
Erythema multiforme, acute lacunar 
.tonsillitis and, 399 
nodosum, acute lacunar tonsillitis 
and, 399 
Escat's position, 170 
Esophagoscopy, 597 
Esophagus, diphtheria of, 485 
foreign bodies in, 577, 596 
paralysis of, 367 
strictures of, 596 
Ethmoid disease, exophthalmos in, 168 
knives, Ballenger's, 244 
perpendicular plate of, removal of, 
in submucous resection of nasal 
septum, 94 
Ethmoidal cells. See also Sinuses, eth- 
moidal, 
empyema of, 148 
and middle turbinal, Ballenger's 
operation for complete ex- 
enteration of, 242 
removal of, Ballenger's opera- 
tion for, 239 
partial, 239 
sinuses, 164, 167 
Ethmoiditis, acute catarrhal otitis media 
and, 708 
atrophic laryngitis and, 471 
chronic moist catarrhal otitis media 
and, 722 
Eustachian "tonsil," 633, 684 
tubes, adenoids and, 346 

affections of, defective hearing 

and, 632 
catheterization of, 695 
clinical anatomy of, 603 
closure of, 602 

curettage of, in epipharyngitis, 
838, 839 
in radical mastoid opera- 
tion, 838 
in deaf -mutism, 1028 
diseases of, 683 
foreign bodies in, 641 
function of, 611 

infection through, 316, 683, 704 
inflammation of, 684 
inflation of, 606 
massage of, 691 
mastoiditis and, 687 
obstruction of, 688 

bougies in, 689, 690, 731 
complete, 688 
diagnosis of, 688 
dilatation for, 689, 690 
diphtheria and, 689 
effect of, 602, 604 



Eustachian tubes, obstruction of, electro- 
lysis for, 689 
epipharyngitis and, 689 
etiology of, 688 
partial, 688 

treatment of, 689, 690, 691 
patency of, 688 

treatment of, 689, 690, 691 
relation of, to hearing, 683 

to middle-ear disease, 683 
stenosis of, 731 
tonsils and, 415 
Ewald's law., 875 
Examination lamp, 39 
Exanthemata, sinus thrombosis and, 746 
Exenteration of mastoid process, land- 
marks after, 835 
Exophthalmos in ethmoid disease, 168 
Exostosis of external auditory meatus, 

661 
Extradural abscess, 792 

chronic otorrhea and, 792 
cholesteatoma and, 792 
etiology of, 792 
location of, 793 
mastoiditis and, 792 
prognosis of, 793 
symptoms of, 792 
treatment of, 793 
surgical, 983 
vertigo in, 793 
Extranasal operations upon maxillary 

sinus, 232 
Extubation, 495 

Eye, diseases of, due to nasal lesions, 34, 
35 
relation of, to nose, throat, and ear, 
30, 31 



Face, adenoid, 339, 345 

erysipelas of, cerebellar nystagmus 
and, 873 
Facial paralysis, 993 

complicating pharyngeal paral- 
ysis, 367 
False croup, 455, 509. See also Laryn- 
gismus stridulus. 
Falsetto voice, 540 
Faradism in diphtheritic paralysis, 367 

for laryngeal paralysis, 520 
Farcy, 323 

Farlow's tonsil punch forceps, 427 
Fauces, affections of, defective hearing 
from, 633, 634 
anatomical landmarks of, 425 
diseases of, 379 

inflammatory, 352 
pillars of, voice and, 530 
syphilis of, 317 
tuberculosis of, 307 
Fenestra cochlea. See Round window, 
vestibuli. See Oval window. 



1048 



GENERAL INDEX 



Ferguson-Pynchon mouth-gag, 340 
Fetterolf's file saw, 80 
Fibro-enchondroma of tonsils, 443 
Fibroma of auricle, 651 

treatment of, 651 
of nose, 276 

treatment of, 276 
operative, 276 
von Langenbeck's, 277 
of pharynx, 370 

aprosexia in, 370 
Ballenger's operation for, 372 
diagnosis of, 371 

from sarcoma of pharynx, 
371 
electrocautery in, 372 
etiology of, 370 
"frog face" in, 370 
prognosis of, 372 
symptoms of, 370 
treatment of, 372 
voice in, 370 
of tonsils, 442 

treatment of, with snare, 443 
Finger dissection of tonsils, 442 
Finsen light, 125, 313 
Fistula in auris congenita, 646 

in circumscribed labyrinthitis, 930 
in diffuse latent suppurative laby- 
rinthitis, 950 
of labyrinth, 648 
nystagmus, 874 
postauricular, closure of, 992 

by the Mosetig-Moorhof 

method, 992 
by the Passow-Trautmann 
method, 992 
salivary, 378 

test of vestibular apparatus, 888 
Flourens' law, 874 

Follicular inflammation of external audi- 
tory apparatus, 657 
tonsillitis, acute, 396 
Foramen, stylomastoid, 995 
Forceps, Asch's septum, 78 

Foster-Ballenger perpendicular bone, 

96 
Ostrum's forward cutting, 228 
Foreign bodies, defective hearing from, 
630 
in ear, 635, 636 
animated, 640 
removal of, 636 

by the agglutination 

method, 637, 638 
by electrocautery, 641 
by forceps, 638 
bv foreign body hook, 

638 
by postauricular in- 
cision, 639 
by syringing, 637 
in tracheobronchos- 
copy, upper, 593 
in tracheoscopy, 484 



by 



Foreign bodies in ear, removal of, 
Voltolini's method, 641 
in esophagus, 577, 596 
in Eustachian tube, 641 
in larynx, 577 
in middle ear, 641 
in nose, 289 

in respiratory passages, 577 
cough from, 577 
etiology of, 577 
pneumonia and, 578 
removal of, 578 
skiagraphy for, 578,586 
symptoms of, 577 
tracheotomy in, 579 
treatment of, 578 
voice and, 577 
spasm of pharynx and. 367 
in trachea, 577 
Fossa, Rosenmuller's, 606, 684, 685, 696 

supratonsillar, 384, 391, 418 
Fossula fenestras cochleae, 609, 610 
Fracture of malleus, 670 

of ossicles, 670 
Freer' s operation for deviations of nasal 

septum, 100, 101 
"Frog face" in fibroma of pharynx, 370 
Frontal-ethmoid operation, 247 
Frontal sinus, 161 
Frontonasal canal, 191, 192 

opening of, variations in, 64 
probing of, 192 
Frostbite, 657 

Fuchsinophiles, Russell's, 287 
Function tests of auditory apparatus, 618 
of hearing, 616 
of vestibular apparatus, 877 
Furunculosis of external auditory meatus, 
657 
after-treatment of 
course of, 658 
etiology of, 657 
hearing in, 658 
symptoms of, 658 
treatment of, 658 
of nose, 288 

etiology of, 288 
symptoms of, 288 
treatment of, 289 



Galton-Edelmann whistle, 626 
Galvanic nystagmus, 874 

test of vestibular apparatus, 891 
Galvanism in degeneration of nerves, 
in paralysis, chronic bulbar, 366 
diphtheritic, 367 
hysterical, of auditory nerve 

1016 
laryngeal, 516, 520 
Galvanocautery. See Electrocautery. 
Ganglion, geniculate, 367 
sphenopalatine, 19, 20 






659 



366 



GENERAL INDEX 



1049 



Gangrene, pulmonary, infection through 

tonsils and, 382 
Gangrenous diphtheria, 479, 481 
Gargling, von Troltsch method of, 686 
Gavage in intubation, 497 
Gelle's test for hearing, 628 
Germ centres of Goodsir, 334 

of tonsils, 384 
Giddiness in circumscribed labyrinthitis, 

932 
Glanders, 323 

diagnosis of, mallein in, 324 
etiology of, 323 
of larynx, 325 
of nose, 323 
pathology of, 324 
of pharynx, 325 
prognosis of, 325 
treatment of, 325 
Gleason's operation for deviation of nasal 

septum, 75, 76, 77, 
Globus hystericus, hyperesthesia of 
pharynx and, 364 
spasm of pharynx and, 367 
Glossodynia in Ungual varix, 351 
Glosso-epiglottic ligament, 348 
Glosso-epiglottidian folds, 408 
Glottic spasm, complete, in adult, 511 
Glottis, spasm of, 509. See also Laryn- 
gismus stridulus. 
Glycosuria, diphtheria and, 480 
Goitre, hyperemia of labyrinth and, 1000 
laryngeal paralysis and, 515, 518 
nasal disease and, 268 
Goldsmith's operation for perforation of 

nasal septum, 109 
Goldstein's chromic acid method of sub- 
mucous cauterization, 141 
plastic flap operation for perfora- 
tion of nasal septum, 104 
Good's operation upon frontal sinus, 

rasps and chisels, 212, 213 
Goodsir, germ centres of, 334 
Gothic arch, 57 

adenoids and, 345 
Gouge, Ballenger's septum, 96 

Hajek's, 94, 96 
Gout, hyperostosis of external auditory 

meatus and, 662 
Granular pharyngitis, 353. See also 

Pharyngitis, chronic. 
Granuloma, chronic, of nose, throat, 
and ear, 304 
syphilitic, diagnosis of, from ade- 
noids, 339 
tuberculous, diagnosis of, from ade- 
noids, 339 
Graves' disease, nasal disease and, 268 
Gustatory functions of nose, 25 



"Haiey pharyngeal polypi," 369 
Hajek-Ballenger mucoperichondria eleva- 
tors, 96 



Hajek-Luc's operation upon frontal sinus, 

216 
Hajek's gouge, 94, 96 
hand burr, 854 

incision in submucous resection of 
nasal septum, 84, 90 
Halle's frontal sinus drills, 211 

operation upon frontal sinus, 210 
Hallucinations in arteriosclerosis of laby- 
rinth, 1005 
Halsted's subdermal suture, 220 
"Hautige braune," 459 
Hawley's spray tubes, 44, 45 
Hay fever, 254. See also Rhinitis, hyper- 
esthetic. 
Hazletine's plastic operation for perfora- 
tion of nasal septum, 105, 106 
Headache in acute diffuse suppurative 

manifest labyrinthitis, 945 
Head lamp, Kierstein's, 39, 40, 579, 589 

pain in abscess of brain, 801 
Hearing in adhesive processes of middle 
ear, 727 
in deaf -mutism, 1028 
defective, 630 

adenoids and, 337, 633, 634 
affections of epipharynx and, 
633, 634 
of Eustachian tubes and, 

632 
of external meatus and, 630 
of fauces and, 633, 634 
of labyrinth and, 634 
of mastoid and, 634 
of membrana tympani and, 

630 
of middle ear and, 631 
ankylosis of ossicles and, 631 
of foot-plate of stapes and, 
631, 632 
caries of ossicles and, 631 
cholesteatoma and, 630 
collapse of cartilaginous meatus 

of ear and, 630 
foreign bodies and, 630 
hypertrophy of tonsils and, 634 
infections and, 633 
inspissated cerumen and, 630 
intracranial tumor and, 1020 
lesions of auricle and, 630 
myringitis and, 631 
polypi and, 631, 632 
functional tests of, 616 
in furunculosis of external auditory 

meatus, 658 
hyperacuteness of, 1016 
alcohol and, 1016 
neurasthenia and, 1016 
tobacco and, 1016 
islands of, 617 

testing of deaf-mutes for, 617 
in myringitis, 672 
neuroses of, 1016 

paths through which sound waves 
reach the labyrinth. 616 



1050 



GENERAL INDEX 



Hearing, physiological facts of, 616 
range of, 616 

relation of Eustachian tubes to, 683 
tests, Bing's, 628 
functional, 616 
Gelle's, 628 
monochord in, 626 
Rhine's, 623, 624 
Schwabach's, 622 
voice, 619 
watch, 620 
Weber's, 621, 622 
of voices, 1019 
Heart in diphtheria, 479 
Heath's operation, 833 
Hematoma, paraffin injection and, 300 
Hemicrania, hyperesthesia acoustica in, 

1018 
Hemilaryngectomy, 558, 560, 562, 566, 

567 
Hemophilia, deaf-mutism and, 1025 
epistaxis and, 285 
hemorrhagic laryngitis and, 472 
operations on tonsil and, 416 
Hemoptysis, spurious, 472 
Hemorrhage, cerebral, accessory nasal 
sinuses and, 187 
deviation of nasal septum and, 66 
into labyrinth, 1001 
laryngeal, 472 
nasal, 284 
Hemorrhagic inflammation of external 
auditory meatus, 660 
laryngitis, 472 
Heredity, nasal inflammation and, 115 
Herpes of auricle, 655 

symptoms of, 655 
treatment of, 655 
zoster of auricle, 656 

treatment of, 656 
of membrana tympani, 656 
High obstruction of nose, 119 

tracheotomy, 490 
Highmore, antrum of. See Sinus, 

maxillary. 
Hillis' position for feeding in intubation, 

497, 499 
Hinsberg's labyrinth operation, 965 

steps of, 865-968 
Hoarseness in acute catarrhal laryngitis, 
449, 453 
in atrophic laryngitis, 471 
in chronic pharyngitis, 354 
in laryngeal carcinoma, 553, 555 
diphtheria, 483 
paralysis, 516, 521 
in papilloma of larynx, 547 
Hodgkin's disease, lymphadenoma of 

tonsils in, 192 
Hoegyes' law, 874 

Holmes' malleable frontal sinus probe, 
192 
scissors, 150, 151 
Horny material in tonsils, 409 
Hurd's bone septum forceps, 97 



Hydrophobia, spasm of pharynx in, 367 
Hydrops laryngis, 453 
Hydrorrhea, nasal, 265 

symptoms of, 265 
treatment of. 266 
Hyper acuteness of hearing, 1016 
Hyperemia of labyrinth, 1000 
Hyperemic laryngitis, 464 
Hyperesthesia acoustica, 670, 689, 1018 
in adhesive processes of middle 

ear, 727 
in concussion of labyrinth, 1011 
in hemicrania, 1018 
in trigeminal neuralgia, 1018 
of pharynx, 364 
Hyperesthetic rhinitis, 254 
Hyperkeratosis of tonsil, 408 
cough in, 409 
electrocautery in, 413 
Hyperkinesis of pharynx, 365, 367 
Hyperleukocytosis in diphtheria, 486 
Hyperosmia, 253 

from irritation of olfactory lobe, 253 
Hyperostosis of bony capsule of laby- 
rinth, 720 
of cochlea, 739 
diffused inflammation of external 

auditory meatus and, 660 
of external auditory meatus, 661 
etiology of, 661 
gout and, 662 
symptoms of, 662 
syphilis and, 662 
treatment of, 662 
of oval window, 739 
of semicircular canals, 740 
of stapes, 739 
Hyperplasia of bony capsule of labyrinth, 
735 
of tonsil, 407, 408 
Hyperplastic rhinitis, 142, 147, 267 
Hypersensitiveness of pharynx, 364 
Hypertrophic laryngitis, chronic, 464 
localized, 468 
ozena, 142 
rhinitis, 142 
Hypertrophy of larynx, 499, 502 

of tonsils, 407, 408 
Hypopharynx, diverticulum of ; 595 

pouch of, 595 
Hyposmia, 253 

Hysteria, sensory neuroses of pharynx 
and, 364 
upper respiratory tract and, 28 
Hysterical paralysis of auditory nerve, 
1016 



Ichthyol solutions, 50 

Idiocy, deaf -mutism and, 1031 

Impacted cerumen, 642 

Incision of membrana tympani, 674, 675, 

676 
i Incus, attachment of, 606 






GENERAL INDEX 



1051 



Incus, destruction of, in chronic mas- 
toiditis, 771 
removal of, 609 

in ossiculectomy, 821, 822 
in radical mastoid operation, 
836, 837 
Indirect laryngoscopy, 546, 549 
Infectious diseases, membranous laryn- 
gitis in, 459 
epiglottitis, acute, 447 
fevers, acute suppurative otitis media 
and, 742, 746, 750 
Infective tonsillitis, 396 
Inflammation, 110 
acute, 110 

microorganisms in, role of, 122 
mucous surfaces and, 111 
nasal, adenoids and, 115 

causes of, exciting, 113 
extranasal, 113 
intranasal, 115 
predisposing, 113 
chronic, 112 
clothing and, 114 
due to obstruction, 115 
exposure and, 114 
heredity and, 115 
reaction of, 110 

promotion of, 122 

by Bier's hyperemic treat- 
ment, 127 
by counterirritation, 122 
by irrigation, 124 
by lavage, 124 
by leeching, 123 
by leukodescent light, 125 
by massage, 124 
opsonic index and, 127 
by pneumomassage, 125 
by poulticing, 123 
by wet cupping, 123 
types of, 111 
Inflation of tympanic cavity, 692 
Infundibulum, 191 

drainage of, 18, 118, 119, 120 
Ingals' operation upon frontal sinus, 214 
Inspiration pneumonia, operations for 

laryngeal carcinoma and, 575 
Inspissated cerumen, defective hearing 

from, 630 
Insufflator, powder, 50 
Internal secretion in tonsils, 392 
Intracranial complications in ' chronic 
mastoiditis, 771 
in disease of sinuses, 207 
lesions, acute simple mastoiditis 

without, 765 
nystagmus, 910 

pyogenic diseases of otitic origin, 789 
tumor, defective hearing from, 1020 
Intradural abscess, 794 
Intralaryngeal laryngotomy, 546 
Intranasal operations upon maxillary 

sinus, 224 
Introitus esophagi, 596 



Intubation in acute catarrhal laryngitis, 
454, 455 
laryngitis in children, 58 
complications of, 496 
in diphtheria, 485, 486, 492 
feeding in, 497 

Casselberry's position for, 497, 

498 
gavage in, 497 
Hillis' position for, 497, 499 
indications for, 454, 455, 458, 460, 

493 
instruments, O'Dwyer's, 493 
for laryngeal paralysis, 524 
membranous laryngitis, 460 
position for, 493, 494, 495 
rectal alimentation in, 499 
removal of tube in, 495, 496 
technique of, 493 
Iodonucleoid in syphilitic stenosis of 

larynx, 503 
Irritation, reflex, spasm of larynx from, 

598 
Ischemia, solutions producing, 56 
Islands of hearing, 617 



Jackson's exhaust pump, 583 
extractor, 586 
forceps, 593 
safety-pin forceps, 592 
self -illuminating tracheobroncho- 
scope, 591 
tube spatula, 588 
slide speculum, 580 
tube, 578, 579, 580 
Jansen's mastoid retractor, 858 

rongeur forceps, 859 
Jansen-Neumann labyrinth operation, 
957 
closure of wound in, 964 
preliminary measures in, 

957 
steps of, 957-964 
Jansen-Stacke incision in radical mastoid 

operation, 846, 847 
Jugular bulb, surgery of, 989, 990, 991 
thrombosis of, 816 
vein, internal, resection of, 987, 988 



Kekatosis obturans, 644 
Kidneys in diphtheria, 480 
Kierstein's head lamp, 39, 40, 579, 5S0, 

589 
Killian's incision in submucous resection 
of nasal septum, 84, 85, 90 
operation upon frontal sinus, 221 
tube, 578, 579 
Kirschner, cells of, 854 



1052 



GENERAL INDEX 



Klebs-Loeffler bacillus, 461, 474, 476, 478, 
480,481,483 
diagnosis of, from staphylo- 
coccus, 478 
from streptococcus, 478 
Neisser's stain for, 477 
Koch's tuberculin in tuberculosis of 

middle ear, 317 
Kramer, method of Eustachian catheter- 
ization, 695, 696 
Krause-Heryng laryngeal forceps, 550 
Krause's nasal snare, 149 

trocar, 225 
Kronlein's landmarks, 979 
Kuhnt-Luc's operation upon frontal 

sinus, 217 
Kuhnt's operation upon frontal sinus, 217 
Kuster's operation upon maxillary sinus, 
231 
osteoplastic, upon frontal sinus, 
218 
Kyle's crypt knife, 420 
malleable tubes, 80 
operation for deviations of nasal 
septum, 80 



Labyrinth, affections of, defective hear- 
ing from, 551 
anemia of, 1001 

etiology of, 1001 

symptoms of, 1001 

treatment of, 1001 
arteriosclerosis of, 1005 

alcoholism and, 1005 

deafness in, 1005 

diagnosis of, 1006 

etiology of, 1005 

hallucinations in, 1005 

lead poisoning and, 1005 

pathology of, 1005 

prognosis of, 1006 

symptoms of, 1005 

syphilis and, 1005 

tinnitus in, 1005 

treatment of, 1006 
bony tissue of, destruction of, in 

tuberculosis of middle ear, 316 
concussion of, 1010 

deafness in, 1011 

detonations and, 1011 

diplacusis acoustica in, 1011 

etiology of, 1010 

hyperesthesia acoustica in, 1011 

nystagmus in, 1011 

symptoms of, 1011 

tinnitus in, 1011 

treatment of, 1012 
in deaf-mutism, 1028 
destruction of, nystagmus in, 908 

traumatic, 907 
diseases of, surgical, 926 
hemorrhage into, 1001 



Labyrinth, hemorrhage in caisson 
workers, 1001 
course of, 1001 
in diabetes, 1001 
in meningitis, 1001 
in nephritis, 1001 
termination of, 1001 
hyperemia of, 1000 
alcohol in, 1000 
from amyl nitrite, 1000 
diphtheria and, 1000 
encephalitis and, 1000 
etiology of, 1000 
goitre and, 1000 
meningitis and, 1000 
mumps and, 1000 
pneumonia and, 1000 
puerperal fever and, 1000 
from quinine, 1000 
from salicylic acid, 1000 
scarlet fever and, 1000 
sinus thrombosis and, 1000 
symptoms of, 1000 
tinnitus in, 1000 
tobacco in, 1000 
treatment of, 1000 
typhoid fever and, 1000 
hyperostosis of bony capsule of, 720 
hyperplasia of bony capsule of, 735 
infection of, in acute suppurative 

otitis media, 748 
inflammation of. See Labyrinthitis. 

deafness in, 1006 
injuries of, 1010 
irritation of, nausea from, 670 

nystagmus from, 670 
mumps in, 1006 
necrosis of, 1008 
operations on, 953 
Bourgnet's, 968 

technique of, 968 
Hinsberg's, 965 

steps of, 965-968 
indications for, 953 
Jansen-Neumann, 957 

closure of wound in, 964 
preliminary measures, 957 
steps of, 957-964 
merits of, 955 
Richards', 971 
physiology of, 861 
spongifying of bony capsule of, 735 
static, 866 

reaction movements of, 868 
spontaneous nystagmus of, 867 
suppuration of, 765 
Labyrinthitis, 1006. See also Labyrinth, 
inflammation of. 
acute diffuse serous, 934 

caloric test in, 937 
degrees of severity of, 

938 
destruction dishar- 
mony in, 938 
etiology of, 934 



GENERAL INDEX 



1053 



Labyrinthitis, acute diffuse serous, 
nausea in, 936 
operation in, indica- 
tions for, 939 
spontaneous nystag- 
mus in, 936 
symptoms of, 934 
treatment of, 939 
vertigo in, 936 
vomiting in, 936 
suppurative manifest, 939 
course of, 945 
deafness in, 942 
destruction dishar- 
mony in, 941 
etiology of, 939 
fever in, 945, 947 
headache in, 945 
onset of, 946 
pointing reaction 

in, 945 
position of patient 

in, 945 
prognosis of, 947 
spontaneous ny- 
stagmus in, 946 
stimulation dis- 
harmony in, 941 
symptoms of, 940 
tinnitus aurium in, 

945 
treatment of, 948 
surgical, 948 
vestibular reaction 
in, 942 
circumscribed, 928 

area of involvement in, 931 
cristas in, inhibited, 931 

stimulated, 931 
deductions from, 914 
diagnosis of, 933 
erosion with fistula in, 904 
etiology of, 929 
fistula in, absence of, 930 
location of, 930 
presence of, 930 
giddiness in, 932 
nausea in, 932 
nystagmus in, 904 
operation in, indications for, 

933 
spontaneous nystagmus in, 932 
symptoms of, 932 

rationale of, 929 
traumatic, 906 

vertigo in, 906 
treatment of, 933 
vertigo in, 904, 932 
diagnosis of, 903 

Barany's fixation apparatus in, 
903 
diffuse latent suppurative, 949 

caloric reaction in, 950 
deafness in, 949 
diagnosis of, 951 



Labyrinthitis, diffuse latent suppurative, 
diagnosis of, 
from cerebellar 
disease, 952 
from disease of 
eighth nerve, 
952 
from hysteria, 951 
from polyneuritis 
(syphilis) of 
eighth and facial 
nerves, 952 
etiology of, 949 
fistula in, 950 
nystagmus in, 909 
purulent discharge in, 

950 
symptoms of, 949 
turning reaction in, 950 
purulent, inflammatory patho- 
logical changes in, 902 
mechanical pathological 
changes in, 902 
general remarks on, 926 
illustrative cases of, 917 
infection in, 899 

through oval window, 900 
operations for, 953 
oval window in, 900 
pathology of, 899 
round window and, 900 
serous, deductions from, 914 
site of, 900 

static labyrinth and, 900 
La Force adentome, 339 
La petae, 321. See Leprosy. 
Lack's operation for collapse of alse nasi, 

303 
Lacunar inflammation, acute, of pharyn- 
geal tonsil, 331 
lingual tonsillitis, acute, 349 
pharyngitis, 353. See also Pharyn- 
gitis, chronic, 
tonsillitis, acute, 396 
Lamp, Kierstein's head, 39, 40 

leukodescent, 46 
Lancet, laryngeal, 455, 464 
Laryngeal apoplexy, 511 
carcinoma, 553 
chorea, 510 
crises, 32 
diphtheria, 483 
forceps applicator, Sajous', 464 

Sajous', 469 
hemorrhage, 472 
lancet, 455, 458, 464 
phthisis, 308 
syncope, 511 
vertigo, 511 
Laryngectomy, complete, 568 

after-treatment of, 573 
indications for, 568 
technique of, 568-574 
partial, 567 

indications for, 567 



1054 



GENERAL INDEX 



Laryngectomy, partial, technique of, 568 
Laryngismus stridulus, 509 

diagnosis of, from membranous 

laryngitis, 461 
enlarged thymus gland and, 509 
etiology of, 509 
sexual excesses and, 489 
treatment of, 509 
uterine disease and, 509 
Laryngitis, acute, in children, 555 
calomel in, 457 
cough in, 455, 456 

codeine for, 458 
diagnosis of, 456 

from diphtheria, 456 
from foreign bodies in 

larynx, 457 
from perichondritis, 

457 
from pseudomembran- 
ous croup, 451 
epipharyngitis in, 455 
etiology of, 455 
intubation in, 458 
prognosis of, 457 
symptoms of, 456 
tracheotomy in, 458 
treatment of, 457 
atrophic, 471 

cough in, 471 
dyspnea in, 471 
ethmoiditis and, 471 
etiology of, 471 
hoarseness in, 471 
pathology of, 471 
pilocarpine in, 472 
prognosis of, 472 
sphenoiditis and, 472 
symptoms of, 471 
treatment of, 472 
catarrhal, acute, 449 
age and, 452 
aphonia in, 449, 453 
arthritis and, 450 
"catching cold" and, 449, 

450 
climate and, 452 
cough in, 453 

codeine for, 455 
deflection of nasal septum 

and, 450 
environment and, 451 
etiology of, 449 
hoarseness in, 449, 453 
hygienic conditions and, 451 
intubation in, 454, 455 
lymphatic communication 

in, 451 
nasal stenosis and, 450 
pathology of, 452 
pilocarpine in, 454 
preexisting diseases and, 

450 
prognosis of, 453 
respiration in, 453 



Laryngitis, catarrhal, acute, sinuitis and, 
450 
symptoms of, 452 
syphilis and, 450, 453 
systemic disturbances and, 

449 
tonsillitis and, 450 
tracheotomy in, 454, 455 
trauma and, 452 
treatment of, 454 
tuberculosis and, 450 
voice in, 453 
chronic, 464 

diagnosis of, 472 

from angina laryngis, 474 
from carcinoma of sub- 
glottic region, 473 
from enchondrosis of laryn- 
geal cartilages, 473 
from laryngeal carcinoma, 

557 
from lupus of larynx, 473 
from pachydermia laryngis, 

473 
from papilloma of larynx, 

474 
from paralysis of posterior 
crico-arytenoid muscle, 
473 
from prolapse of ventricle 

of larynx, 473 
from sarcoma of larynx, 473 
from syphilis of larynx, 473 
from tuberculosis of larynx, 
473 
mouth-breathing and, 465 
tobacco and, 465 
unstableness of vasomotor sys- 
tem and, 466 
croupous, 459 
diphtheritic, 459 
hemorrhagic, 472 

albuminuria and, 472 
diabetes and, 472 
etiology of, 472 
hemophilia and, 472 
leukemia and, 472 
symptoms of, 472 
syphilis and, 472 
treatment of, 473 
tuberculosis and, 472 
typhoid fever and, 472 
variola and, 472 
voice in, excessive use of, 472 
yellow fever and, 472 
hypertrophic, diffused, adenoids and, 
465, 467 
alcohol and, 465, 467 
deflections of nasal septum 

and, 465, 467 
diagnosis of, 467 
epipharyngitis and, 467 
etiology of, 465 
faucial tonsils and, 467 
mouth-breathing and, 465 



GENERAL INDEX 



1055 



Laryngitis, hypertrophic, diffused, path- 
ology of, 466 
polypi and, 465, 467 
prognosis of, 467 
Sajous' laryngeal forceps in, 

467 
sinuitis and, 465, 467 
smoking and, 465, 467 
symptoms of, 466 
trades and, 466 
treatment of, 467 
voice in, 466 

discrete, 468 

cough in, 468 
diagnosis of, 469 

from rhinoscleroma, 
469 
dyspnea in, 466, 469 
etiology of, 468 
. pathology of, 468 
symptoms of, 468 
tracheotomy in, 469 
treatment of, 469 

localized, 468 
hypoglottica, 468 
membranous, 459 

aphonia in, 460 

Bacillus pyocyaneus in, 460 

calomel fumigations in, 462 

cardiac infection in, 461 

cough in, 460 

diagnosis of, 461 

from diphtheria, 461 

from laryngismus stridulus, 

461 
from retropharyngeal ab- 
scess, 461 
from spasmodic laryngitis, 
461 

dyspnea in, 460 

edema of bronchial mucous 
membrane in, 461 

etiology of, 459 

infectious diseases and, 459 

intubation in, 460 

laryngeal spasm in, 460 

onset of, 460 

pathology of, 460 

pneumococcus in, 460 

spirillum in, 460 

staphylococcus in, 460 

streptococcus in, 460 

symptoms of, 460 

tracheotomy in, 460 

treatment of, 461 

voice in, 460 
phlegmonous, acute, 458 
cough in, 458 
dyspnea in, 458 
erysipelas and, 458 
etiology of, 458 
pathology of, 459 
prognosis of , "459 
scarification in, 459 
symptoms of, 458 



Laryngitis, phlegmonous, acute, trache- 
otomy in, 459 
treatment of, 459 
sicca, 471 

singing voice and, 534 
spasmodic, diagnosis of, from mem- 
branous laryngitis, 461 
stridulosa, 455. See Laryngitis, 

acute, in children, 
subglottic, 456 
subjective, chronic, 468 
supraglottis 456 

syphilitic, diagnosis of, from laryn- 
geal carcinoma, 557 
tuberculous, 308 

diagnosis of, from laryngeal 

carcinoma, 557 
pregnancy and, 314 
in pregnant women, 314 
Laryngocele, 501 

Laryngofissure, 546, 548, 558, 560, 561 
hemorrhage in, 565 
incisions in, 563, 564 
indications for, 561, 562 
for laryngeal paralysis, 524 
rectal anesthesia for, 563 
in stenosis of larynx, 505, 506, 565 

syphilitic, 503 
technique of, 562 
Laryngoscopy, direct, 546, 549, 587 
anesthesia for, 587 
instruments for, 599 
position of patient in, 588 
slide speculum in, examination 
through, 589 
indirect, 546, 549 

technique of, 549 
in laryngeal carcinoma, 556 
Laryngotomy, intralaryngeal, 546 
Larynx, abductor muscles of, paralysis of, 
453 
abscess of, 463 

edema of larynx and, 462 
etiology of, 463 

perichondritis of larynx and, 462 
tracheotomy in, 464 
treatment of, 464 
tuberculosis and, 463 
carcinoma of, 553 

diagnosis of, from tuberculosis 
of larynx, 312 
catarrh of, acute, 449 
deformities of, 501 
diseases of, 445 
edema of, 462 

abscess of larynx and, 462 
asphyxia in, 462 
Bright's disease and, 462 
diabetes and, 462 
dyspnea in, 463 
etiology of, 462 
Ludwig's angina and, 462 
pathology of, 462 
perichondritis of larynx and, 462 
peritonsillitis and, 462 



1056 



GENERAL INDEX 



Larynx, edema of, prognosis of, 463 
sclerosis of liver and, 462 
symptoms of, 463 
syphilis and, 462 
tracheotomy in, 463 
treatment of, 463 
tuberculosis and, 462 
valvular lesions of heart and, 462 
voice in, 463 
erysipelas of, 463 
foreign bodies in, 577 

diagnosis of, from acute 
laryngitis in children, 457 
glands of, 325 
hyperplasia of, 501 
hypertrophy of, 501, 502 
papillomatous, 502 
mouth-breathing and, 502 
lupus of, 306 

diagnosis of, from tuberculosis 
of larynx, 312 
lymphatic drainage of, 551, 552 
malformations of, 501 
muscles of, abductor, paralysis of, 
515 
adductor, paralysis of, 514, 515 
aryteno-epiglottic, paralysis of, 

516 
cricothyroid, paralysis of, 514, 

515, 543 
intrinsic, paralysis of, 453, 512 
tensor, external, of vocal cords, 

paralysis of, 515 
thyro-epiglottic, paralysis of, 516 
neoplasms of, 544 

benign, diagnosis of, from laryn- 
geal carcinoma, 557 
etiology of, 544, 545 
irritation and, 545 
location of, 544 
malignancy of, tendency toward, 

546 
malignant, 551. See also Car- 
cinoma, laryngeal, 
mouth-breathing and, 545 
syphilis and, 545 
tuberculosis and, 545 
varieties of, 544 
neuralgia of, 510 
neuroses of, motor, 508 
papilloma of, 546 
perichondritis of, 457 

edema and, 462, 463 
pouches of, dilatation of, 501 
singing voice and, 527 
spasm of, 460, 508, 509 
stenosis of, 501, 502 

laryngeal diphtheria and, 483 
syphilis and, 501 
syphilis of, 319 

diagnosis of, from tuberculosis 
of larynx, 312 
tuberculosis of, 309 
Lateral sinus, thrombosis of, 810 
Lavage, 124 



Lavage of ethmoidal sinus, 194 

of frontal sinus, 191 

of maxillary sinus, 192 

of sphenoidal sinus, 194 
"Le con proconsulair " symptom in diph- 
theria, 485 
Lead poisoning, arteriosclerosis of laby- 
rinth and, 1005 
Leeching, 123 

for acute catarrhal otitis media, 715, 
716 

for simple acute mastoiditis, 768 

for suppurative otitis media, 775, 776 
Leiter coil, 406, 650, 654, 768, 769 
Leontiasis, 321 

Lepra anesthetica seu nervosa, 323 
Leprosy, 321 

anesthetic, 323 

etiology of, 322 

infection in, modes of, 322 

nasal secretion in, contagiousness of, 
322 

pathology of, 322 

prognosis of, 323 
Leprous stenosis of larynx, 504 
Leptomeningitis, 794 

Cheyne-Stokes respiration in, 795 

ethmoiditis and, 794 

lumbar puncture in, 795 

otitic origin of, 794 

prognosis of, 795 

sphenoiditis and, 794 

symptoms of, 795 

Westphal's symptoms in, 795 
Leptothrix in tonsils, 408 
Leukemic deafness, 1006 
Leukocytosis in reaction of inflammation, 

110, 122 
Leukodescent lamp, 46, 125, 136, 190, 306, 
313, 356, 406 

light, 125 
Lingual tonsil, 348, 384 

varix, 350 
Lip reading, 1032 
Lipoma of nose, 280 

of pharynx, 373 

of tonsils, 442 
Lips, paralysis of, in chronic bulbar paral- 
ysis, 366 
Liver in diphtheria, 480 

sclerosis of, edema of larynx and, 462 
Localized hypertrophic laryngitis, 468 
Localizer, Ostrum's, 223 
Locomotor ataxia, deafness from, 1022 

laryngeal paralysis and, 521 
Loeb's projections of accessory sinuses of 

nose, 162 
"Lop ear," 645 
Low tracheotomy, 490, 594 
Lowenberg method of Eustachian cathe- 
terization, 696 
Lower tracheobronchoscopy, 594 
Ludwig's angina, edema of larynx and, 

462 
Lumbar puncture, 790 



GENERAL INDEX 



1057 



Lumbar puncture in leptomeningitis, 

795 
Lumpy jaw, 325 
Lungs in deaf-mutism, 1030 

in diphtheria, 479 
Lupous stenosis of larynx, 504 
Lupus, arsenic paste for, 305, 306 
of auricle, 306 

treatment of, 306 
of larynx, 306 

diagnosis of, from chronic 
laryngitis, 473 
from tuberculosis of larynx, 
312 
of nose, 304 

electrocautery in, 305 
etiology of, 304 
radiotherapy for, 305 
radium in, 305 
Rontgen rays in, 306 
symptoms of, 304 
treatment of, 305 
ultraviolet rays in, 306 
pachydermia laryngis and, 500 
of pharynx, 306 
Lymphadenoma of pharynx, 369 

of tonsils in Hodgkin's disease, 444 
Rontgen rays in, 444 
Lymphatic drainage of larynx, 551, 552 
glands in diphtheria, 480 
of neck, 388 

hypertrophy of, 333 
involvement of, in laryngeal 
carcinoma, 555 
suppurative diseases of ear and, 
28 
infection through tonsils, 379, 381, 

382, 387, 388, 390 
system, infection through, 32 
vessels of neck, 388 
tonsillar, 387, 388 
Lymphoid tissue in adenoids, 335 
of pharynx, 354 
of tonsil, faucial, 383, 384 
lingual, 348, 351 
Lymphoma of nose, 278 

of pharynx, 369 
Lymphosarcoma of pharynx, 375 



M 



McKernon's rongeur forceps, 858 
Mackenzie's reflex area, 34 
Macrotia, 646 

treatment of, 647 
Malaria, nose and, 29 
Mallein in diagnosis of glanders, 324 
Malleus, 602 

attachment of, 606 
fracture of, 670 
removal of, 609 

in ossiculectomy, 821, 822 
in radical mastoid operation, 
836, 837 



Manometer in inflation of tympanic 

cavity, 697 
Margo supratonsillaris, 408, 419, 424, 

425, 430 
Massage, 124 

in adhesive processes of middle ear, 

730 
apparatus, 40 

Delstanche's, 40, 42 
Pynchon's, 41 
for chorditis nodosa, 471 
of eardrum, 40, 42 
of Eustachian tube, 691 
external mechanical, inflation of 

tympanic cavity by, 701 
for suppurative otitis media, 776 
Masseur, Weaver's intratympanic, 690 
Mastoid affections, defective hearing 
from, 634 
antrum, location of, 827 

necrosis of, 603, 609, 759 
opening of, 828 
otitis media and, 770 
bone, sclerosis of, in chronic mastoid- 
itis, 771 
cells, distribution of, 610 

exenteration of, 831, 833, 834 
in radical mastoid opera- 
tion, 833 
cortex, removal of, 830, 833 

in radical mastoid opera- 
tion, 833 
emissary vein, tenderness over, in 

thrombosis of lateral sinus, 812 
operation, facial paralysis and, 994 
perichondritis after, 601, 654 
radical, 793, 833 

after-treatment of, 846, 

847 
Ballance flap method in, 

840, 854 
Ballenger's modification of, 
848 
incision in, 849, 850 
curettage of Eustachian 

tube in, 838 
danger to oval window in, 

836 
disfigurement after, 848 
exenteration of mastoid 

cells in, 833 
facial paralysis and, 834 
incision in. Ballance, 841, 
843 
in infants, 857 
Jansen-Stacke, 846, 

847 
Panse, 846 
postauricular, 859 
"shepherd's crook," 

841, 843 
Siebermann's Y, S45 
indications for, 760, 764, 

773 
in infants and children, S59 



67 



1058 



GENERAL INDEX 



Mastoid operation, radical, plastic sur- 
gery of cutaneous meatus 
in, 840 
removal of incus in, 836, 837 
of malleus in, 836, 837 
of mastoid cortex in, 

833 
of necrosed bone from 
tympanic cavity in, 
838 
of outer wall of atrium 

in, 838 . 
of outer wall of attic 

in, 838 
of posterior wall of 
meatus in, 834 
Thiersch grafts after, 844, 

853 
Trautmann tongue flap 
method in, 846 
simple, 824 

after-treatment in, 833 
Airport's mallet for, 828 
anatomical landmarks for, 

826, 827 
antrum in, location of, 827 

opening of, 828 
Ballenger's mastoid peri- 
osteal elevator in, 826 
cells in, exenteration of, 831 
closure of cutaneous wound 

in, 832 
cortex in, removal of, 830 
dressing in, 832 
elevation of cutaneous peri- 
osteal flaps in, 823 
incisions in, 824, 825 

Whiting's, 825 
irrigation in, 832 
Russian perforator for, 827, 

828 
technique of, 824 
process, caries of, 772 

destruction of, in tuberculosis 

of middle ear, 316 
diseases of, 765 
exenteration of, landmarks after, 

835 
necrosis of, 772 
osteosclerosis of, 771 
periostitis of, acute, 770 
etiology of, 770 
treatment of, 770 
Wilde's incision for, 
770 
tuberculosis of, 314 
Mastoiditis. See also Otitis media, sup- 
purative, 
acute, Bier's hyperemic treatment 

in, 769 
Bezold's, 857 

treatment of, surgical, 859, 860 
chronic, 770, 833 

caries of mastoid process in, 772 
diagnosis of, 770 



Mastoiditis, chronic, incus in, destruction 
of, 771 
intracranial complications in, 

771 
membrana tympani in, 771 
necrosis of mastoid process in, 

772 
neuralgia in, 771 
operation for, radical mastoid, 

773 
prognosis of, 772 
sclerosis of mastoid bone in, 771 
Siegle's otoscope in, 771 
symptoms of, 770 
treatment of, 773 
Eustachian tube and, 687 
extradural abscess and, 792 
incision for, Whiting's, 825 

Wilde's, 824 
otitis media and, suppurative acute, 

747 
pathology of, 784 
primary, acute, 823 

meningitis and, 824 
thrombosis of lateral sinus 
and, 824 
sequelae of, 765 
simple, acute, 765 

Bier's treatment for, 769 
cold applications for, 768 
"dip" of postsuperior wall 

in, 766 
without intracranial lesions, 

765 
leeching for, 768 
pain in, 766 
perforation in, 767 
Schwartze's point of tender- 
ness in, 766 
spontaneous cures of, 767 
symptoms of, 765 
torticollis in, 766 
treatment of, 767 
subacute, 769 

surgical intervention in, indications 
for, 823, 824 
Mathieu's tonsillotome, 417 
Maxilla, superior, resection of, for nasal 

polypus, 277 
Maxillary sinuitis, hyperesthetic rhinitis 
and, 255 
sinus, 166 
Mayer's nasal tube splints, 79 
Meatomastoid operation, 848 

indications for, 756, 759, 760, 
764, 768 
Meatus, auditory, external, 601 

in acute suppurative otitis 

media, 744 
affections of, defective hear- 
ing from, 630 
epithelial plugs in, 644 
exostosis of, 661 
follicular inflammation of, 
657 



GENERAL INDEX 



1059 



Meatus, auditory, external, furunculosis 
of, 657 
hyperostosis of, 661 
inflammation of, croupous, 
661 
prognosis of, 661 
treatment of, 661 
diffused, 659 

duration of, 660 
etiology of, 659 
hyperostosis in, 

660 
periostitis and, 

660 
prognosis of, 660 
symptoms of, 659 
treatment of, 660 
hemorrhagic, 660 

treatment of, 660 
mycosis of, 663 
stricture of, 663 

diphtheria and, 663 
cartilaginous, of ear, collapse of, 

defective hearing from, 630 
cutaneous, plastic surgery of, in rad- 
ical mastoid operation, 840 
Mediastinum, tumors of, laryngeal paral- 
ysis and, 515, 518, 520, 521, 522 - 
Medulla oblongata, lesions of, laryngeal 

paralysis from, 521 
Membrana flaccida, perforation of, sig- 
nificance of, 783 
tectoria, 614, 615 
tympani, abscess of, 671 
adenoids and, 346 
adhesions of, operations for, 734 
adhesive processes of middle ear 

and, 726 
affections of, defective hearing 

from, 630 
atrophy of, 679 
calcareous deposits in, 679, 721, 

788 
in chronic mastoiditis, 771 

moist catarrhal otitis 
media, 720, 721 
dermic layer of, ulceration of, 

673 
diseases of, 669' 
function of, 611 
herpes zoster of, 656 
incision of, 674, 675, 676, 749, 
767, 768, 775 
in adhesive processes of 

middle ear, 678 
curved bistoury for, 675 
with electrocautery, 680 
indications for, 677 
knife for, 675 
with lancet, 681 
location for, 675 
methods of, 680 
in myringitis with abscess 

formation, 677 
in ossiculectomy, 819, 820 



Membrana tympani, incision of, in otitis 
media, 677 
acute catarrhal, 
678 
suppurative, 
678 
chronic catarrhal, 
677 
postoperative considera- 
tions, 682 
in suppuration of middle 

ear, 678, 679 
in tenotomy of tensor tym- 
pani muscle, 677 
inflammation of, 671, 673. See 

also Myringitis, 
injuries of, 669 

etiology of, 669 
nausea in, 670 
nystagmus in, 670 
prognosis of, 670 
symptoms of, 670 
treatment of, 671 
malformations of, 669 
massage of, 40, 42. 

Beck's mercury, 43 
operations for, 733 
perforation of, 603, 673, 754, 755 
in acute suppurative otitis 

media, 744, 745 
central, 755, 757 
deafness from, 673 
marginal, 759 
significance of, 669 
spontaneous, 676 
retraction of, 683 
rupture of, 670 
tuberculous, 315 
Membranous croup, 483 
idiopathic, 459 
laryngitis, 459 
Meniere's disease, 634, 1002 
deafness in, 1002 
diagnosis of, 1002 

from Meniere's symptom 
complex, 1002 
dizziness in, 1002 
nausea in, 1002 

nystagmus in, spontaneous, 1002 
prognosis of, 1003 
tinnitus in, 1002 
treatment of, 1003 
vertigo in, 1002 
vomiting in, 1002 
symptom complex, 1002 

diagnosis of, from Meniere's 

disease, 1002 
pneumomassage in, 1004 
Rinne test in, 1004 
tinnitus in, 1003 
treatment of, 1004 
Meningitis, 789 

primary mastoiditis and, S24 
suppurative otitis media and, 
746, 74S, 752 



1060 



GENERAL INDEX 



Meningitis, ethmoid operation and, 247 
hemorrhage into labyrinth in, 1001 
hyperemia of labyrinth and, 1000 
infection of tympanic cavity and, 608 
metastatic, in thrombosis of lateral 

sinus, 812 
after middle turbinotomy, 153 
nystagmus in, 910 
serosa, 790 

dizziness in, 790 
etiology of, 790 
nystagmus in, 790 
symptoms of, 790 
torticollis in, 790 
treatment of, 791, 983 
sinuitis and, 164, 180 
following turbinotomy, 242 
Mentality in adenoids, 337 
Menthol in tuberculosis of larynx, 313 
Mesopharynx, inflammatory diseases of, 

352 
Meyer's ring curette, 339, 344 
Michel's metal clamp suture, 857, 859 

suture clip forceps, 859 
Microtia, 646, 647 

Middle ear, inflation of, in acute suppura- 
tive otitis media, 749 
suppuration, bacteriology of, 

786, 787 
tuberculosis of, 314 
Mikulicz's cells, 287 

Miller's asthma, 455, 509. See also Lar- 
yngismus stridulus. 
Mixed diphtheria, 481 

infection in diphtheria, 479 
laryngeal diphtheria, 484 
Mogiphonia, 511 
Monophasia, 1020 
Morve, 323 
Mosetig-Moorhof plastic operation, 990, 

992 
Mosher's frontal-ethmoid operation, 247 

safety-pin holder, 592 
Moure's operation for deviations of nasal 
septum, 81 
upon ethmoidal sinuses, 250 
Mouth-breathing in adenoids, 337 
chronic laryngitis and, 465 
diffused hypertrophic laryngitis 

and, 465 
neoplasms of larynx and, 545 
papillomatous hypertrophy of 
larynx and, 502 
Mucin in nasal hydrorrhea, 265 
Mucopurulent rhinitis, 154 
Mucosa knife, Ballenger's, 96 
Mucous membrane, sloughing of, in diph- 
theria, 479 
rhinitis, simple, 154 
Multiple sclerosis, laryngeal paralysis 
and, 521 
throat in, 32 
Mumps, hyperemia of labyrinth and, 
1000 
labyrinth in, 1000 



Muscle, constrictor, superior, of pharynx, 
385, 391, 420, 425 
digastric, in excision of external 

carotid artery, 378 
palatoglossus, 384, 391 
palatopharyngeus, 384, 391 
stapedius, 607, 612 
sternocleidomastoid, lymphatic rela- 
tions of, 387 
stylohyoid, in excision of external 

carotid artery, 378 
stylopharyngeus, 995 
tensor tympani, 607, 612 
tenotomy of, 677 
Muscles in diphtheria, 480 

of larynx, 512, 513, 515 
Mutism, 1029 

Mycosis of external auditory meatus, 
664, 665 
leptothricia of tonsils, 408 
Myles' operation upon maxillary sinus, 

225 
Myringitis, 671 
chronic, 673 

defective hearing from, 631 
diagnosis of, 672 
eruptions in, 671 
etiology of, 671 
hearing in, 672 
prognosis of, 672 
symptoms of, 671 
treatment of, 672 
Myxoma of nose, 269 

classification of, surgical, 272 
etiology of, 269 
pathology of, 270 
prognosis of, 272 
removal of, with snare, 274 
symptoms of, 270 
treatment of, 272, 273 
of pharynx, 370 
Myxosarcoma of pharynx, 375 



N 



Nasal chambers, 17 

singing voice and, 532 
deformity in cretinism, 298 
diphtheria, 481, 482, 485 
disease, goitre and, 268 

Graves' disease and, 268 
singing voice and, 526, 534 
hemorrhage, 284 
hydrorrhea, 265 

lesions, diseases of eye and, 34, 35 
neuroses, 253 
obstruction, 115 

acute catarrhal otitis media and, 
707 
respiration, 23 

secretion in empyema of accessory 
sinuses, 31 
in leprosy, contagiousness of, 
322 



GENERAL INDEX 



1061 



Nasal secretion in obstructive devia- 
tions of nasal septum, 65 
septum, 17 

cartilage of, reformation of, 101, 

102 
deflection of acute catarrhal 

laryngitis and, 450 
deformities of, 57 
deviations of, 57 

cartilaginous, 60 

operations for, 67, 68 
classification of, 59 
correction of, 62, 67 
diffused hypertrophic laryn- 
gitis and, 465, 467 
epistaxis and, 66 
etiology of, 57, 58 
hemorrhage and, 66 
hyperesthetic rhinitis and, 

255 
obstructive, asthma in, 65 
dizziness in, 63 
headache in, 63 
nasal secretions in, 65 
stenosis in, 65 
turbinated bones in, 63 
vertigo in, 63 
operations for, Asch- 
Mayer's, 77, 78, 79 
Bosworth's, 70, 71, 72 
Freer's, 100, 101 
Gleason's, 75, 76, 77 
Kyle's, 80 
Moure's, 81 
open method of, 100, 

101 
Price-Brown's, 81 
Roe's, 77 
Sluder's, 74, 75 
Watson's, 73, 74 
osseous, 60 

operations for, choice 
of, 68, 69 _ 
symptoms of, objective, 66 
subjective, 63 
hypertrophies of, soft, 70 

cautery for, 70 
lesions of, obstructive, 62 
operations for, 67, 68, 69 
perforation of, 103 
etiology of, 103 
operations for, 104 

Ballenger's mucosa 
swivel knife for, 105 
Goldsmith's, 109 
Goldstein's plastic flap, 

104 
Hazletine's plastic, 

105, 106 
Yankauer's intranasal 
suture, 107, 108 
in scarlet fever, 103 
symptoms of, 103 
treatment of, 104 
tuberculosis of nose and, 307 



Nasal septum , spurs on, removal of, 69, 
72 
submucous resection of, 82-100 
accidents in, 99, 100 
after-treatment in, 98 
anesthesia in, 82, 84 
dressing for, 98 
elevation of mucoperi- 
chondrium in, 
90 
of periosteum in, 
85, 90 
elevators for, 85, 86, 87 
Foster-Ballenger for- 
ceps in, 93, 94, 96 
Freer's method, 100, 

101 
gouge for, 94, 96 
incision in, through 
cartilage, 91 
Hajek's, 84, 90 
Killian's, 84, 85, 
90 
inspection of field of 

operation in, 97, 98 
open method of, 100, 

101 
position of patient in, 

82 
splints for, 98 
spokeshave in, use of, 

93 
swivel knife in, use of, 
91, 92, 96 
sinuses, accessory, cerebral hemor- 
rhages and, 187 
optic neuritis and, 187 
splint, Carter's, 292 
stenosis, respiration and, 17 
suppuration, 160 
tachycardia, 268 
tube splints, Mayer's, 79 
Nausea in acute diffuse serous labyrinth- 
itis, 936 
in circumscribed labyrinthitis, 932 
in injuries of membrana tympani, 

670 
from irritation of labyrinth, 670 
in Meniere's disease, 1002 
Neck, tumors of, laryngeal paralvsis and, 

521 
Negative air pressure, treatment of sinu- 
itis by, 196 
pressure apparatus, 45 
Neisser-Ernst bodies in diphtheria, 477 
Neisser's stain for Klebs-Loeffler bacillus, 

477 
Neoplasms of larynx, 544 
of nose, 269 
of pharynx, 368, 374 
of subglottic space, 546 
of tonsils, 442, 444 
Nephritis, hemorrhage into labvrinth in. 

1001 
Nerve, acusticus, paralysis of, 515 



1062 



GENERAL INDEX 



Nerve, auditory, 613 

distribution of, 613 
paralysis of, 1015, 1016 
auricularis posterioris profunda, 995 
chorda tympani, relations of, 607, 

608 
facial, anastomosis of, with hypo- 
glossal nerve, 995-999 
anatomy of, 994, 995 
paralysis of, 515, 993, 994 
relation of, to aditus ad antrum, 
834 
to annulus tympanicus, 835 
to horizontal semicircular 

canals, 835 
to tympanic cavity, 836 
surgery of, plastic, 993-995 
glossopharyngeal, paralysis of, 515 
hypoglossal, anastomosis of, with 
facial nerve, 995-999 
paralysis of, 993, 994 
surgery of, plastic, 993, 994 
infra-orbital, relation of, to maxillary 

sinus, 167 
laryngeal, inferior, paralysis of, 516, 
517 
recurrent, paralysis of, 516, 517, 

520 
superior, paralysis of, 515 
optic, relation of, to sphenoidal sinus, 

169 
pneumogastric, 513, 515, 516, 518 
irritation of, shock from, 575 
relations of, 518 
spinal accessory, 515, 518, 521 
Nervous cough, 511 

system in diphtheria, 479, 486 
Neumann's law, 875 

noise apparatus, 627 
Neuralgia in acute suppurative otitis 
media, 744 
in chronic mastoiditis, 771 
of larynx, 510 
of pharynx, 365 
Neurasthenia, hyperacuteness of hearing 
and, 1016 
laryngeal paralysis and, 522, 523 
nystagmus in, 907 
vertigo in, 907 
Neuritis, facial paralysis and, 993 

optic, accessory nasal sinuses and, 
187 
sinuitis and, 187 
Neuroses of larynx, 508 
Nitrate of silver, solutions of, 48 
Nitrous oxide anesthesia in tonsillotomy, 

436 
Nodules, singer's, 469 
Noises, subjective, 1018 
Nose, accessory sinuses of, 19, 161 
actinomycosis of, 325 
adenoma of, 278 
alternating stenosis of, 137 
anatomy of, clinical, 17 
anemia and, 28 



Nose, angioma of, 278 

aquiline or hump, operation for, Bal- 
lenger's intranasal, 
296 
external, 295 
attic of, 254 
blood supply of, 21 
carcinoma of, 281 
chambers of, 17 
colloid degeneration of, 287 
deformities of, correction of, 291 

paraffin injections for, 297 

Thiersch graft for, 293 
digestive tract and, 29 
diphtheria of, 482, 483 
dislocated, 294, 295 
edema of, acute circumscribed, 264 
erectile tissue of, 18 
excretory organs and, 30 
fibroma of, 276 
as a filter, 24, 25 
foreign bodies in, 289 
functions of, 23, 25 
furunculosis of, 288 
general medicine and, 26 
glanders of, 323 
hemorrhage from, 284 
hypersensitive area in, nervous cough 

from, 511 
inflammatory diseases of, 110 
lipoma of, 280 
long or drooping, operation for, Bal- 

lenger's, 297 
lupus of, 304 
lymphoma of, 278 
malaria and, 29 
meatuses of, 18 

middle, 18 

myxoma of, 269 

superior, 19 
neoplasms of, 269 
nerve supply of, 19 
nerves of, sensory, 19 
neuroses of, 253 

obstruction of, 115, 117, 119, 120 
osteoma of, 279 
papilloma of, 275 
physiology of, 22 
polypi of, 269 
rheumatic fever and, 29 
saddle, paraffin injections for, 298 
sarcoma of, 281 
screw-worms in, 289 
septum of, 17 
stenosis of, 31 
streptodiphtheria of, 483 
submucous resection of. See Nasal 

septum, submucous resection of. 
"swell bodies" of, 18, 24 
syphilis of, 33, 317 
turbinated bones of, 17, 18 
twisted or crooked, Ballenger's 

operation for, 291, 292, 293 
"vicious circle" of, 199 
"key" to, 199 



GENERAL INDEX 



1063 



Nose, "vicious circle" of, polypi in, 269 
Nystagmus in acute destruction of one 
labyrinth, 90S 
cerebellar, 872 

erysipelas of face and, 873 
of scalp and, 873 
in circumscribed labyrinthitis, 904 
in concussion of labyrinth, 1011 
in diffuse latent suppurative laby- 
rinthitis, 909 
induced, after-, 873 
after-after-, 873 
caloric, 874 
characteristic of, 873 
fistula, 874 
galvanic, 874 
primary, 873 
in injuries of membrana tympani, 670 
of intracranial origin, 910 
from irritation of labyrinth, 670 
laws of, 874 

Ewald's, 875 
Fleurens', 874 
Hoegye's, 874 
Neumann's, 875 
in meningitis, 910 

serosa, 790 
in neurasthenics, 907 
spontaneous, in acute diffuse serous 
labyrinthitis, 936 
suppurative manifest 
labyrinthitis, 946 
in circumscribed labyrinthitis, 

932 
in Meniere's disease, 1002 
in suppurative otitis media, 752 
toxemia and, 907 
vestibular, deductions from, 913 
spontaneous, 870 

characteristics of, 871 



Obstructive lesions of nasal septum, 62 

rhinitis, 142 
Occupation deafness, 1012, 1013 
Ocular symptoms in sinuitis, 164, 169, 

181, 186, 187 
O'Dwyer's intubation instruments, 493 
Odor, subjective, significance of, 173 
Odynophagia, 449 
(Edema. See Edema. 
Office equipment, 36-47 
Ointments, 52 
Olfaction, neuroses of, 253 
Olfactory fissure, obstruction of, 21, 119, 
168 
anosmia and, 253 
pus in, 19, 160 
lobe, irritation of, hyperosmia from; 

253 
nerve, 21 
Ollier's operation for sarcoma of nose, 282 



Open method of operation for deviations 

of nasal septum, 100, 101 
Operating chair, 36, 37 
Ophthalmic veins, infection through, 32 
Opsonic index, 127 

Optic neuritis, accessory nasal sinuses 
_ and, 187 
sinuitis and, 187 
Orbito-ethmoid operation upon ethmoidal 

sinuses, 251 
Orthoform in tuberculosis of larynx, 313 
Osseous deviations of nasal septum, 60 
Ossicles of ear, 607 

ankylosis of, in adhesive processes 
of middle ear, 728 
in deaf -mutism, 1028 
defective hearing from, 631 
caries of, defective hearing from, 631 
fracture of, 670 

loss of, in acute suppurative otitis 
media, 748 
Ossiculectomy, 609, 759, 819 
after-treatment of, 823 
anesthetic for, 819 

Delstanche's ring knife for, 821 
dressing in, 823 
hemorrhage in, 823 
incision of membrana tympani in, 

819, 820 
preparation of ear for, 819 
removal of incus in, 821, 822 

of malleus in, 821, 822 
Sexton's knives for, 821 
Osteoma of epipharynx, 280 
of nose, 279 

diagnosis of, 279 
pathology of, 279 
symptoms of, 279 
treatment of, 279 
Osteoplastic operation, Beck's double, 
upon frontal sinus, 219 
Kuster's, upon frontal sinus, 218 
Osteosclerosis of mastoid process, 771 
Ostrum's forward cutting forceps, 228 

localizer, 223 
Othematoma, 648 

dementia and, 648 
diagnosis of, 650 

from angioma of auricle, 651 
etiology of, 647 
Leiter coil for, 650 
pain in, 649 
prognosis of, 650 
resemblance of, to perichondritis of 

auricle, 654 
symptoms of, 649 
treatment of, 650 
Otitis externa, 657 

crouposa, 661 
diffusa, 659 
hemorrhagica, 660 
parasitica, 664 
interna, paralitica , 1006 
media, acute lacunar tonsillitis and, 
398 



1064 



GENERAL INDEX 



Otitis media, adenoids and, 338 
bacteriology of, 785, 786 
catarrhal, acute, 703 

auscultation in, 712 
bacteriology of, 703, 

704 
bone conduction in, 

711, 713 
climate and, 706 
diabetes and, 710 
diagnosis of, 709 
duration of, 713 
epipharyngeal diseases 

and, 708 
ethmoiditis and, 708 
etiology of, 703 
faucial tonsils and, 708 
incision of membrana 

tympani in, 678 
inflation of tympanic 

cavity for, 714, 715 
intracranial complica- 
tions in, 710 
leeching for, 715, 716 
membrana tympani in, 

711 
nasal diseases and, 
707 
obstruction and, 
707 
onset of, 710 
pathology of, 709 
pneumomassage for, 

715 
prognosis of, 713 
Rinne test in, 711 
sphenoiditis and, 708 
symptoms of, 709, 710 
syphilis and, 708 
treatment of, 713, 714 
tubal disease and, 526 
tuberculosis and, 708 
weather and, 704, 705, 

706 
Weber test in, 711 
chronic moist, 718 

adenoids and, 723 
autophony in, 720 
deafness from, 718 
deafness in, 719 
ethmoiditis and, 

722 
etiology of, 718 
membrana tym- 
pani in, 720, 721 
paracusis Willisii 

in, 720 
passive hyperemia 

in, 724 
prognosis of, 722 
sphenoiditis and, 

722 
symptoms of, 719 
tinnitus aurium in, 
719 



Otitis media, catarrhal, chronic moist 
treatment of, 722, 723 
catarrhalis chronica, 724 

sicca, 724 
incision of membrana tympani 

in, 677 
insidiosa, 735 
mastoid antrum and, 770 
pathology of, 784 
sclerotica, 724 

sinus thrombosis and, 748, 752 
suppurative, acute, 742 

abscess of brain and, 

748 
adhesions in, 747 
compression of air in 

meatus in, 749 
course of, 745 
deafness from, 745, 747 
death from, 748 
diabetes and, 744 
diagnosis of, 748 
drainage in, 749 
etiology of, 742 
external auditory mea- 
tus in, 744 
hearing in, 745 
incision of membrana 

tympani in, 678 
infectious fevers and, 

742, 746, 750 
inflation of middle ear 

in, 749 
labyrinth in, infection 

of, 748 . 
mastoiditis and, 747 
membrana tympani in, 

744, 748 
meningitis and, 746, 

748, 752 
mucous membrane in, 

loss of, 748 
neuralgia in, 744 
ossicles in, loss of, 748 
pain in, 743, 748 
perforation in, 744, 746 
predisposing causes of, 

743 
probe in, use of, 748 
prognosis of, 749 

as to hearing, 
756 
Rinne test in, 747 
Rivinian segment and, 

743 
secretions in, 745 
sequelae of, 746 
subjective noises in, 

745 
symptoms of, 743 
temperature in, 744, 

748 
terminations of, 746 
treatment of, 749, 756, 
757, 759 



GENERAL INDEX 



1065 



Otitis media, suppurative, acute, tym- 
panic murmur in, 
749 
Weber test in, 745 
in children, 750 

convulsions in, 751 
symptoms of, 751 
treatment of, 752 
adenoids and, 346 
chronic, 752 

adenoids and, 757 
dry gauze dressings for, 

758 
epipharyngitis and, 758 
forms of, 753 
otorrhea in, 753 
pain in, 753 
perforations in, 754 
sinuitis and, 758 
symptoms of, 752 
treatment of, 781 
alcohol, 760, 781 
with boric acid 

powder, 782 
with camphoroxol, 

782 
with compound 
tincture of ben- 
zoin, 782 
by curettage, 760 
dry gauze, 781 
by irrigation, 782 
via Weber- Li el 
catheter, 758 
free drainage for, 779 
incision of membrana tym- 

pani in, 775 
leeching in, 775, 776 
massage for, 776 
nystagmus in, 790 
radiant light for, 775 
removal of granulations in, 
779 
morbid material in, 779 
sequelae of, 765 
treatment of, 774 
vaccine therapy for, 776 
syphilitic, 1007 
tuberculous, 316 
Otomycosis, 664 
Otopiesis, 1030 

Otorrhea, chronic, in abscess of brain, 752 
dangers of, 787 
extradural abscess and, 792 
life insurance and, 752, 836 
treatment of, 757, 759 
in chronic suppurative otitis media, 

753 
in deaf -mutism, 1030 
Otosclerosis, 735 

diagnosis of, 738 
etiology of, 735 
pathology of, 737 
prognosis of, 740 
symptoms of, 738 



Otosclerosis, synonyms of, 735 
treatment of, 740 
mechanical, 741 
medical, 740 
prophylactic, 741 
surgical, 741 
Otoscope, Siegle's, 745, 750 
Oval window, 608 

hyperostosis of, 739 

combined with otitis media, 
740 
membrane of, 607 
Oxyecoia, 1016 
Ozena, 154 

in atrophic rhinitis, 156 

hypertrophic, 142 

in syphilis of internal ear, 1007 



Pachydermia laryngis, 500 
accessory, 500 

diagnosis of, from chronic laryn- 
gitis, 473 
electrolysis for, 500, 501 
lupus and, 500 
papilloma of larynx and, 546 
perichondritis and, 500 
potassium iodide in, 500 
syphilis and, 500 
tuberculosis and, 500 
Pachymeningitis circumscripta, treat- 
ment of, surgical, 983 
externa circumscripta, 792. See also 

Extradural abscess, 
interior circumscripta, 794 
Pancreas in diphtheria, 480 
Panotitis, 747 

Panse incision in radical mastoid opera- 
tion, 846 
Papilloma of larynx, 546 
aphonia in, 547 

diagnosis of, from chronic laryn- 
gitis, 474 
dyspnea in, 547, 548 
etiology of, 546 
hoarseness in, 547 
pachydermia laryngis and, 546 
pathology of, 548 
prognosis of, 548 
reflex cough in, 368 
symptoms of, 547 
syphilis and, 546 
treatment of, 548, 549 
tuberculosis and, 546 
of nose, 275 

treatment of, 275 
of pharynx, 368 

electrocautery in, 368 
treatment of, 368 
of tonsils, 442 

cough in, 442 
Papillomatous hypertrophy of lar}Tix, 
502 



1066 



GENERAL INDEX 



Paquelin cautery for angioma of auricle, 

651 
Paracentesis, 677 
Paracusis, 1016 
duplex, 1017 
Willisii, 739, 1017 

in adhesive processes of middle 

ear, 727 
in chronic moist catarrhal otitis 
media, 720 
Paraffin injections in atrophic rhinitis, 158 
for deformities of nose, 297 
hematoma and, 300 
in rhinolalia pata, 298 
Paralysis of abductor muscles of larynx, 
453 
angioneurotic, of auditory nerve, 

1015 
chronic bulbar, galvanism in, 366 
paralysis of lips in, 366 
pneumonia and, 366 
from sunstroke, 366 
diphtheria antitoxin and, 489 
diphtheritic, 486 

galvanism in, 367 
of esophagus, 367 
facial, 993 

etiology of, 993 

mastoid operation and, 994 

neuritis and, 993 

of otitic origin, 993 

paralysis of pharynx and, 367 

perineuritis and, 993 

radical mastoid operation and, 

834 
surgery of, plastic, 993, 994, 995 
treatment of, 994 
tumors and, 994 
of hypoglossal nerve, 993 
hysterical, of auditory nerve, 1016 
galvanism for, 1016 
treatment of, 1016 
of intrinsic muscles of larynx, 453 
laryngeal, 512, 524 

anesthesia of larynx in, 516 
aneurysm and, 522 

of aorta and, 517, 520 
of subclavian and, 518, 521 
aphonia in, 516, 519, 521 
bilateral, 519 

abductor, 522 
"cadaveric" position of vocal 

cords in, 519, 521 
cough in, 519 
diphtheria and, 515, 520 
from disease of superior laryn- 
geal nerve, 515 
dyspnea in, 519, 521, 522 
enlarged thyroid gland and, 

521 
etiology of, 515 
faradism for, 520 
galvanism for, 516, 520 
goitre arid, 515, 518 
hoarseness in, 516, 521 



Paralysis, laryngeal, indication of aneu- 
rysm of arch of aorta, 515 
intubation for, 524 
laryngofissure for, 524 
from lesions of medulla oblon- 
gata, 521 
of nuclei of spinal accessory 
nerve, 521 
lobar pneumonia and, 516 
locomotor ataxia and, 521 
multiple sclerosis and, 521 
neurasthenia and, 522, 523 
pericarditis and, 515, 518 
phonation in, 519 
pleurisy and, 515, 518 
pneumonia and, 516 
progressive bulbar paralysis and, 

521 
scoliosis and, 518 
syphilis and, 519, 521, 522 
thyroidectomy in, 521 
tracheotomy in, 520, 522, 523, 

524 
traumatisms and, 515, 518 
tuberculosis and, 515 
tumors and, 515, 518, 520 
of brain and, 521 
of mediastinum and, 515, 

518, 520, 521, 522 
of neck and, 521 
typhoid fever and, 515 
unilateral, 517, 520 
voice in, 516, 522 
of pharynx, 365, 366, 367 
of posterior crico-arytenoid muscle, 
diagnosis of, from chronic laryn- 
gitis, 473 
progressive bulbar, laryngeal paral- 
ysis and, 521 
rheumatic, of auditory nerve, 1015 
from tumor of brain, 1021 
Parosmia, 253 

in sinuitis, 186 
Paresthesia of pharynx, 364 
Passow-Trautmann plastic operation, 

989, 990 
Patency of Eustachian tube, 688 
Perception of tone, 618 
Perforation of membrana tympani, 673 

of nasal septum, 103 
Pericarditis, laryngeal paralysis and, 515, 

518 
Perichondritis of auricle, 601, 654 

mastoid operation and, 599, 654 
resemblance of, to othematoma, 

654 
symptoms of, 654 
treatment of, 654 
of cricoid cartilage, 457 
of larynx, 457 

diagnosis of, from acute laryn- 
gitis in children, 457 
from laryngeal carcinoma, 
557 
edema of larynx and, 462, 463 



GENERAL INDEX 



1067 



Perichondritis, pachydermia laryngis 

and, 500 
Perilymph, 613 

Perineuritis, facial paralysis and, 993 
Periosteum, elevation of, in submucous 

resection of nasal septum, 85, 90 
Periostitis acute, of mastoid process, 770 
diffused inflammation of external 
auditory meatus and, 659 
Peritonsillar abscess, 404. See also Peri- 
tonsillitis. 
Peritonsillitis, 404 

Ballenger's operation for, 407 
complications of, 405 
edema of larynx and, 462 
etiology of, 404 
sequelae of, 405 
symptoms of, 404 
thrombophlebitis and, 405 
treatment of, 405, 406 
Perpendicular plate of ethmoid, removal 
of, in submucous resection of nasal 
septum, 94 
Pes anserinus, 378, 995 
Pharyngeal adenoids, 333 
scissors, 347 

tonsils, development of, 384 
Pharyngitis, catarrhal, simplea cute, 352 
chronic, 353 

cough in, 354 

electrocautery in, 355 

etiology of, 353 

hoarseness in, 354 

pathology of, 354 

prognosis of, 355 

rheumatic diathesis and, 354, 

355 
symptoms of, 354 
tobacco and, 353, 354 
treatment of, 355 
granular, 353. See also Pharyngitis, 

chronic, 
lacunar, 353. See also Pharyngitis, 

chronic, 
singing voice and, 531 
Pharyngotomy, subhyoid, 565 
indications for, 565 
technique of, 565, 566, 567 
Pharynx, akinesis of, 365 
anesthesia of, 364 
angioma of, 373 
cystoma of, 369 
erectile tumors of, 373 
fibroma of, 370 
glanders of, 325 
hyperesthesia of, 364 

globus hystericus and, 364 
hyperkinesis of, 365, 367 
hypersensitiveness of, 364 
lipoma of, 373 
lupus of, 306 
lymphadenomata of, 369 
lymphoid tissue of, 354 
lymphoma of, 369 
malformations of, 362 



Pharynx, muscles of, paralysis of, 366 
myxomata of, 370 
neoplasms of, 368, 374 
neuralgia of, 365 
neuroses of, 364, 565 

rheumatism and, 365 
tobacco and, 364 
papillomata of, 368 
paralysis of, bulbar, acute, 365, 366 
chronic, 366 
central,. 365, 366 
diphtheritic, 366 

symptoms of, 366 
treatment of, 367 
facial paralysis and, 367 
peripheral, 366 
paresthesia of, 364 

during menopause, 365 
sarcoma of, 374 

diagnosis of, from fibroma of 
pharynx, 371 
sensory neuroses of, hysteria and, 

364 
singing voice and, 531 
spasm of, 367 

brain tumor and, 367 
foreign bodies and, 367 
globus hystericus and, 367 
in hydrophobia, 367 
prognosis of, 367 
symptoms of, 367 
treatment of, 367 
stenosis of, 362 
syphilis of, 317 
teratoma of, 368 
tuberculosis of, 307 
Phlegmonous angina in diphtheria, 482 
diphtheria, 481 
laryngeal diphtheria, 484 
laryngitis, acute, 458 
lingual tonsillitis, acute, 349 
rhinitis, 289 
tonsillitis, 404 
Phonation, 23 

in laryngeal paralysis, 519 
Phonatory spasm, 509 
Phthisis, pharyngeal, 308 
"Pigeon chest," adenoids and, 347 
Pilocarpine in acute catarrhal laryngitis, 
472 
in atrophic laryngitis, 472 
Pischel's collodion dressing, 144 
Pleurisy, laryngeal paralysis and, 515, 518 
Plica salpingopharyngeus, 696 

supratonsillaris, 385, 396, 402, 408 
tonsillaris, 385, 396, 402, 408, 425 
triangularis, 387, 402, 419 
Plicotomy, 682 ^ 
Pneumococcus in membranous larvngitis, 

460 
Pneumomassage, 40, 42, 125 

for acute catarrhal otitis media, 715 
in hyperostosis of bony capsule of 

labyrinth, 741 
in Meniere's symptom complex, 1004 



1068 



GENERAL INDEX 



Pneumonia, chronic bulbar paralysis and, 
366 
foreign bodies in respiratory passages 

and, 578 
hyperemia of labyrinth and, 1000 
inspiration, operations for laryngeal 

carcinoma and, 575 
laryngeal paralysis and, 516 
lobar, laryngeal paralysis and, 516 
metastatic, in thrombosis of lateral 

sinus, 812 
tracheoscopy and, 584 
Polar granules in diphtheria, 477 
Politzerization, 694, 699 
Politzer's acoumeter, 1029 
bag, 699, 700 
method of inflation of tympanic 

cavity, 699 
modified method of inflation of tym- 
panic cavity, 700 
Pollen of plants, hyperesthetic rhinitis 

and, 257 
Polypi, defective hearing from, 631, 632 
diffused hypertrophic laryngitis and, 

465, 467 
hyperesthetic rhinitis and, 256 
nasal, 269. See also Myxoma of nose, 
sinuitis and, 177, 180, 184, 189 
within "vicious circle" of nose, 269 
Postauricular fistula, closure of, 992 

for removal of foreign bodies in 
ear, 639 
Postdiphtheritic paralysis, 486 

respiration in, 486 
Postnasal "dropping," significance of , 173 
Potassium iodide in actinomycosis, 328 
in pachydermia laryngis, 500 
subglottic stenosis and, 507 
Pouch of hypopharynx, 595 

of larynx, dilatation of, 501 
Poulticing, 123 
Powder insufflator, 50 
Pregnancy, tuberculous laryngitis and, 

314 
Pressure, atrophic rhinitis due to, 155 
Price-Brown's operation for deviations of 

nasal septum, 81 
Primary mastoiditis, acute, 823 
Prolapse of ventricle of Morgagni, 502 
Prominentia canalis facialis, 608 
semicircularis lateralis, 609 
Promontorium, 608 
Pmssak's space, 610, 717 

suppuration of, 612 
Pseudocroup, 455 
Pseudodiphtheria bacilli in diphtheria, 

478 
Pseudomembrane in diphtheria, 478 
appearance of, 479 
effect of antitoxin on, 489 
formation of, 479 
Pseudomembranous angina, 400 
croup, 459 

diagnosis of, from acute laryn- 
gitis in children, 457 



Pseudomembranous sore throat, 366 
"Pseudotabes, diphtheritic," 486 
Puberty, influence of, on voice, 525 
Puerperal fever, hyperemia of labyrinth 

and, 1000 
Pulmonary gangrene from infection 

through tonsils, 381, 382 
Puncture, lumbar, 790 
Pynchon-Golding-Bird's curette, 344 
Pynchon's cautery dissection of tonsils, 
429 
massage apparatus, 41 
submerged tonsil, 408 
tonsil hemostat, 422 
Pyogenic diseases, intracranial, of otitic 
origin, 789 



Q 



Quinine, hyperemia of labyrinth from, 

1000 
Quinlan's forceps, 344 
Quinsy, 404. See also Peritonsillitis. 



R 



Radiant light in treatment of suppura- 
tive otitis media, 775 
Radical mastoid operation, 760, 764, 773, 

833 
Radiotherapy in lupus of nose, 305 

for tuberculosis of nose, 308 
Radium in lupus of nose, 305 

in tuberculosis of larynx, 315 
Ray fungus, 325 
Reaction of inflammation, 110 
Recessus epitympanicus, 608, 609 
Rectal alimentation in intubation, 499 

operations for laryngeal cancer 
and, 575 
anesthesia for laryngofissure, 563 
Reflex, cardiac, in operations for 
carcinoma, 565 
neuroses, nasal, 254 
phenomena of nasal origin, 21 
toxemic, 29, 30 
Refraction, disorders of, in sinuitis, 185 
Reissner's membrane, 615 
Resection in adenoids, 336, 345 

submucous, of nasal septum, 82, 100 
Respiration in acute catarrhal laryngitis, 
453 
in laryngeal diphtheria, 483 
methods of, improper, 532 
nasal, 23 

in postdiphtheritic paralysis, 486 
Respiratory functions of nose, 23 
passages, foreign bodies in, 577 
tract, upper, epithelium of, 450 
function of, 26 
infections of, 32 
inflammation in, 450 

inoperable cancer of, 377 



GENERAL INDEX 



1069 



Retropharyngeal abscess, 359 

boric acid in, 361, 362 
diagnosis of, 359 
from aneurysm, 359 

from membranous laryn- 
gitis, 461 
etiology of, 359 
iodoform emulsion in, 360, 361, 

362 
operation for, 360, 361 
prognosis of, 360 
symptoms of, 359 
treatment of, 360 
Reverdin's needle, 859 
Rheumatic diathesis, chronic pharyngitis 
and, 354, 355 
fever from infection through tonsils 
381, 382 
nose and, 29 
paralysis of auditory nerve, 1015 
Rheumatism, acute articular, acute lacu- 
nar tonsillitis and, 398 
operations on tonsils and, 
416 
chronic lacunar tonsillitis and, 403 
neuroses of pharynx and, 365 
Rhinal hydrorrhea, 265 
Rhinitis, acute, 130 

constitutional dyscrasias and, 

130 
etiology of, 130 

pathology of, 133 
prognosis of, 134 
specific fevers and, 130 
''swell bodies" in, 131 
symptoms of, 133 
treatment of, 134 

with leukodescent lamp, 136 
atrophic, 154 

cyanotic congestion and, 154, 

155 
due to pressure, 155 

etiology of, 155 
prognosis of, 155 
symptoms of, 155 
treatment of, 155 
suppurative sinuitis, 156 
etiology of, 154 
ozena in, 156 
paraffin injections in, 158 
simple, 155 
symptoms of, 157 
treatment of, 157 
chronic, with collapse of erectile 
tissue, 153, 154 
dry, 154 
with turgescence, 137 

electrocauterization for, 139 
etiology of, 137 
pathology of, 139 
prognosis of, 139 
submucous cauterization 

for, 141 
symptoms of, 138 
treatment of ; 139 



Rhinitis, hyperesthetic, 254 

alcohol injections for, 263 
climatic influence and, 256 
deflection of septum and, 255 
dizziness in, 255 
etiology of, 254 
exciting causes of, 256 
geographical distribution of, 256 
maxillary sinuitis and, 255 
pathology of, 257 
pollen of plants and, 257 
polypi and, 256 
predisposing causes of, 254 
prognosis of, 258 
symptoms of, 257 
treatment of, 259 

with Dunbar's serum, 262 

of dyscrasias in, 259 

of local marked lesions in, 

259 
of neuroses in, 259 
palliative, 261 
protective, 260 
serum, 262 
Stein's, 263 
hyperplastic, 142, 147, 267 
etiology of, 147 
prognosis of, 149 
rhinoscopy in, anterior, 148 
symptoms of, 148 
treatment of, 151 
hypertrophic, 142 

electrocautery, 144 
etiology of, 142 
pathology of, 142 
prognosis of, 143 
"swell bodies" in, 143 
symptoms of, 143 
treatment of, 144 
mucopurulent, 154 
mucous, simple, 154 
obstructive, 142 
phlegmonous, 289 
suppurative, 160 
Rhinolalia pata, paraffin injection in, 

298 
Rhinorrhea, cerebrospinal, 265, 26>6 
etiology of, 266 
treatment of, 267 
Rhinoscleroma, 286 

bacteriology of, 286 
definition of, 286 

diagnosis of, from discrete hyper- 
trophic laryngitis, 469 
etiology of, 286 
pathology of, 287 
Rontgen rays in, 288 
symptoms of, 287 
thiosinamin in, 288 
treatment of, 288 
Rhinoscopy, anterior, in hyperplastic 

rhinitis, 148 
Rhodes' tonsil punch forceps, 427 
Richards' method of adenectomy, 344 
operation upon labyrinth, 971-974 



1070 



GENERAL INDEX 



Richards' operation upon vestibule, 971 
Right-angle knife, Ballenger's, 417 
Rinne test in acute catarrhal otitis media 
711 
suppurative otitis media, 
747 
in adhesive processes of middle 

ear, 728 
for hearing, 623, 624 
in hyperostosis of bony capsule 

of labyrinth, 739 
in Meniere's symptom complex, 

1004 
in syphilis of internal ear, 1007 
Rivinian segment, 610 

acute suppurative otitis media 
and, 743 
Robertson's operation on tonsils, 428 

tonsil scissors, 428 
Roe's operation for deviation of nasal 

septum, 77 
Rontgen rays, 127 

in lupus of nose, 305 
in lymphadenoma of tonsils, 444 
in rhinoscleroma, 288 
in tuberculosis of larynx, 313 
Rosenmiiller's fossa, 333, 338, 340, 606, 

684, 685, 696 
Rose's position, 282, 372, 418, 594 
Round window, 608 
Round-cell sarcoma of pharynx, 374 
Ruault's tonsil punch forceps, 428 
Rupture of membrana tympani, 670 
Russell's fuchsinophiles, 287 
Russian perforator, 827 



Saccule, cristae of. 870 

Saddle nose, paraffin injections of, 298 

Sajous' laryngeal forceps, 467, 469 

applicator, 464 
Salicylic acid, hyperemia of labyrinth 

from, 1000 
Salivary fistula, 378 
Salpingitis, 684 
Salpingopharyngeal fold, 332 
Santorini, fissures of, 601 
Sarcoma of auricle, 652 

diagnosis of, 653 
prognosis of, 653 
treatment of, 653 
of larynx, diagnosis of, from chronic 

laryngitis, 473 
of nose, 281 m 

diagnosis of, 281 
Ollier's operation for, 282 
prognosis of, 281 
treatment of, 281 
of pharynx, 374 

diagnosis of, from actinomycosis 

of pharynx, 327 
varieties of, 374, 375 
Satyriasis, 321 



Saw, antrum, Vail's, 226 
Bosworth's, 71 
Fetterolf's, 80 
Scalp, erysipelas of, cerebellar nystagmus 

and, 873 
Scarification in acute phlegmonous laryn- 
gitis, 459 
Scarlet fever, hyperemia of labyrinth and, 
1000 
perforation of nasal septum in, 

103 
tonsils and, 381 
Scheibel's suture forceps, 859 
Schroetter's laryngeal tubes, 505 
Schwabach's test for hearing, 739 
Schwartze's point of tenderness in simple 

acute mastoiditis, 766 
Scissors, Holmes', 150, 151 
Sclerosis of mastoid bone in chronic 
mastoiditis, 771 
of middle ear, 724 

multiple, laryngeal paralysis and, 521 
Scoliosis, laryngeal paralysis and, 518 
Screw- worms in nose, 289 
Secretion, internal, in tonsils, 392 
Seller's solution, 55, 355, 549 
Semicircular canals, physiology of, 861 
function of, 613 

relation of, to facial nerve, 
835 
hyperostosis of, 740 
Semon's law, 519, 556 
Sensory aphasia, 1020 
nerves of nose, 19 
neuroses, nasal, 254 
Septic angina in diphtheria, 482 
diphtheria, 481 
laryngeal, 484 
Septicemia, diphtheria and, 481 
Septum forceps, Hurd's bone, 97 
gouge, Ballenger's, 96 
nasal, 17 

nasi. See Nasal septum, 
speculum, Ballenger-Foster, 97 
Serous meningitis, 790 
Serum treatment of hyperesthetic rhinitis, 

262 
Sexton's foreign body forceps, 639 

ossiculectomy knives, 821 
"Shepherd's crook" incision in radical 

mastoid operation, 841, 843 
Shock in operations for laryngeal carci- 
noma, 574 
Shrapnell's membrane. See Membrana 

flaccida. 
Shutz adenotome, 344 
Siebermann's Y-incision in radical mas- 
toid operation, 845 
Siegle's otoscope, 603, 610, 717, 728, 745, 

750, 771, 783, 788, 1004 
Silent croup, 460 
Simpson's nasal sponge splint, 97 
Simulated deafness, 1013 
Singer's nodules, 469, 544, 545 
Singing voice, 525 



GENERAL INDEX 



1071 



Sinuitis, 161, 162, 164, 166, 168 

acute catarrhal laryngitis and, 450 

anosmia in, 186 

auditory functions and, disturbance 

of, 1SS 
caries of teeth and, 177 
catarrhal, acute, treatment of, 190 

chronic, treatment of, 190 
cerebral hemorrhage and, 187 
chronic suppurative otitis media and, 

75S 
coryza and, 188 
diagnosis of, differential, 169 
diffused hypertrophic laryngitis and, 

465, 467 
digestive disturbances from, 27 
dizziness in, 163, 186 
due to pressure in middle turbinated 

region, 188 
empyema in, 169 
Escat's position in, 170 
etiology of, 176 
exciting causes of, 177 
headache in, 163, 171, 185 
hypothetical cases of, 170, 175 
intracranial complications in, 164 
maxillary, hyperesthetic rhinitis and, 

255 
meningitis and, 164, 180 
nasal causes of, 177 
ocular symptoms in, 164, 169, 186, 

187 
optic neuritis and, 187 
pain in, 163, 168, 185 
parosmia in, 186 
pathology of, 178 
polypi and, 177, 180, 184, 189 
pus in, 163, 165, 168, 170, 171, 184 
refraction in, disorders of, 185 
singing voice and, 534 
skiagraphy in, 162, 163, 182, 183 
special senses in, disturbance of, 186 
strabismus and, 174 
suppurative, atrophic rhinitis due 
to, 156 
chronic, due to obstructive 
lesions, 189 

treatment of, 191 
symptoms of, 162, 163, 181, 184, 185 
syphilis and, 176 
tenderness on pressure in, 162, 163, 

171, 185 
transillumination in, 171, 181, 182 
treatment of, 188 

indications for, 188 
by irrigation, 191-195 
by lavage, 191-195 
by negative air pressure, 196 
operative, 199, 207 
tuberculosis and, 176 
vaccine therapy for, 196, 197 
vertigo in, 163, 186 
Sinus, accessory, of nose, 19, 161. See 
also Sinus, ethmoidal, 
frontal, etc. 



Sinus, accessory of nose, disease of, vac- 
cine therapy in, 196 
division of, 161, 167 
empyema of, 169 

nasal secretions in, 31 
inflammation of. See 

Sinuitis. 
irrigation of, 195 
Loeb's projections of, 162 
operations for, 202 
surgery of, 199 

indications for, 205 
cavernous, thrombosis of, 817 
disease of, asthenopia in, 205 
hay fever and, 207 
intracranial complications in, 

207 
ocular symptoms in, 205, 206 
skiagraphic indications in, 206 
ethmoidal, anterior, 164 
anatomy of, 164 
inflammation of, 164. See 
also Sinuitis. 
operations for, choice of, 204, 
205 
pus in, 165 
skiagraphy in, 165 
suppuration in, 164, 165 
lavage of, 194 
operations for, 239, 247 
Ballenger's, 239, 242 
external, 250 
Moure's external, 250 
orbito-ethmoid, 251 
posterior, 167 

anatomy of, 167 
inflammation of, 168. See 

also Sinuitis. 
operations for, choice of, 
203 
frontal, 161 

anatomical variations of, 161 
inflammation of, 161. See also 
Sinuitis. 
dizziness in, 163 
headache in, 163 
intracranial complications 

in, 164 
meningitis and, 164 
mucous discharge in, 163 
ocular symptoms in, 164 
pain in, 163 
pus in, 163 
redness in, 163 
skiagraphy in, 162 
swelling in, 163 
symptoms of, 162, 163 
tenderness to pressure in, 

162, 163 
vertigo in, 163 
irrigation of, 171 
lavage of, 191 
operations for, 207 

after-treatment in, 209, 212, 
213, 220, 223 



1072 



GENERAL INDEX 



Sinus, frontal, operation for, Ballenger's 
intranasal, 207 
Beck's double osteoplastic, 

219 
choice of, 204, 205 
external, 215 
Good's, 212 
Hajek-Luc's, 216 
HaUe's, 210 
Ingals', 214 
Killian's, 221 
Kuhnt-Luc's, 217 
Kuhnt's, 217 
Kuster's osteoplastic, 218 
probing of, 172, 192 
surgery of, 202, 207 
lateral, thrombosis of, 789, 810, 984 
maxillary, anatomy of, 166 

inflammation of, 166. See also 
Sinuitis. 
etiology of, 166, 167 
teeth and, 167 
irrigation of, 170 
lavage of, 192 

technique of, 193 

through alveolar process, 

194 
through canal external to 
teeth, 194 
operations for, 224 
alveolar, 230 
Caldwell-Luc's, 231 
Canfield-Ballenger's an- 
trum, 233 
choice of, 203 
Cooper's, 230 
Corwin's, 227 
Denker's, 233 
extranasal, 230 
intranasal, 224 
Kuster's, 231 
Myles', 225 
Vail's, 226 
relation of intra-orbital nerve 
to, 167 
to teeth, 230 
transillumination of, 277 
sphenoidal, 168 

anatomy of, 168 
inflammation of, 168. See also 
Sinuitis. 
ocular symptoms in, 169 
pain in, 168 
pus in, 168 
lavage of, 194 
operations for, Ballenger's, 249 

choice of, 203 
relation of optic nerve to, 169 
thrombosis, cholesteatoma and, 763 
exanthemata and, 746 
hyperemia of labyrinth and, 

1000 
otitis media and, 748, 752 
tonsillaris, 387 
Skiagraphy in disease of sinuses, 206 



Skiagraphy for foreign bodies in respi- 
ratory passages, 578, 586 
in sinuitis, 162, 165, 182, 183 
Skin in diphtheria, 486 
Sloughing of mucous membrane in diph- 
theria, 479 
Sluder's guillotine operation on tonsils, 
430 
contra-indications to, 
436 
operation for deviation of nasal 
septum, 74, 75 
Smallpox, deaf -mutism and, 1027 
Smell, sense of, 22 

Smoking, diffused hypertrophic laryn- 
gitis and, 465, 467 
Snare, Krause's nasal, 149 

removal of myxoma of nose with, 272 
Soft hypertrophies of nasal septum, 70 
Sore throat, clergyman's, 353. See also 
Pharyngitis, chronic, 
pseudomembranous, 366 
Spasm, glottic, complete, in adult, 511 
of glottis, 509. See also Laryngismus 
stridulus, 
from irritation, reflex, 508 

of trunk of recurrent laryn- 
geal nerve, 508 
of larynx, 508, 509 

adductor, 509. See also Laryn- 
gismus stridulus, 
in membranous laryngitis, 460 
in tetanus, 508 
tonic, of central origin, 508 
of pharynx, 367 
phonatory, 509 

of tensor muscles of vocal cords, 509 
Spasmodic laryngeal cough, 510 
Spasmus glottidis, 509. See also Laryn- 
gismus stridulus. 
Speculum, Allen's nasal, 97 

Ballenger-Foster septum, 97 
Jackson's slide, 580 
Spedalskhed, 321. See also Leprosy. 
Speech in deaf-mutism, 1029 
defects of, 536 

adenoids and, 335, 539 
aprosexia and, 538, 539 
classification of, 537 
deaf-mutism and, 542 
emotion and, 536 
mentality and, 536, 537 
origin of, abdominal, 540 
epipharyngeal, 539 
faucial, 539 
larjTigeal, 540 
lingual, 539 
nasal, 538 
thoracic, 540 
Sphenoidal sinus, 168 
Sphenoiditis, acute catarrhal otitis media 
and, 708 
atrophic laryngitis and, 471 
chronic moist catarrhal otitis media 
and, 722 



GENERAL INDEX 



1073 



Sphenoiditis, leptomeningitis and, 794 [ 
Sphenomaxillary fissure, growths in, 371 
Sphenopalatine ganglion, 19, 20 
Spinal accessory nerve, nuclei of, lesions 
of, laryngeal paralysis from, 521 
cord, lesions in, due to diphtheria, 
479 
Spindle-cell sarcoma of pharynx, 375 
Spirillum in membranous laryngitis, 460 
Spitting blood, 472 
Spleen in diphtheria, 480 
Splints, Mayer's nasal tube, 79 
Simpson's nasal sponge, 97 
Spokeshave, 146 
Chaleway's, 72 

in submucous resection of nasal 
septum, 93 
Spray tubes, 43, 44 

De Vilbiss', 44 
Hawley's, 44, 45 
Spurious hemoptysis, 472 
Stacke protector, 609, 994 
Stammering, 537 

pulmonary tuberculosis and, 540 
Stapedectomy in hyperostosis of bony 

capsule of labyrinth, 741 
Stapes, attachment of, 606 

foot-plate of, ankylosis of, defective 

hearing from, 648, 649 
hyperostosis of, 739 
Staphylococcus albus in acute infectious 
epiglottitis, 448 
diagnosis of, from Klebs-Loeffler 

bacillus, 478 
in membranous laryngitis, 460 
Stem's treatment of hyperesthetic rhi- 
nitis, 263 
Stenosis, alternating, of nose, 137 
of Eustachian tube, 731 
of larynx, 501, 502 

in laryngeal diphtheria, 483 

laryngofissure in, 505, 506, 565 

leprous, 504 

lupous, 504 

Schroetter's laryngeal tubes in, 

505 
subglottic, 507 
syphilitic, 502 

chronic edema in, 503 
cicatricial contraction in, 

503 
cough in, 503 
dyspnea in, 503 
hyperplastic growths in, 

503 
iodonucleoid in, 503 
laryngofissure in, 503 
papillary growths in, 503 
voice in, 503 
webs in, 503 
tracheotomy in, 504, 505, 506 
traumatic, 504 
treatment of, 504 
tuberculous, 504 
ventricular eversion and, 504 

6a 



Stenosis, nasal, 31 

acute catarrhal laryngitis and, 

450 
respiration and, 17 
in obstructive deviations of nasal 

septum, 65 
of pharynx, 362 

subglottic, potassium iodide and, 507 
Sterilizer for instruments and gauze, 47 
Stethoscope test for simulated deafness, 

1014 
Stomach, diphtheria of, 485 
Strabismus, sinuitis and, 174 
Street's tonsil hypodermic syringe, 418 
Streptococcus aureus in acute infectious 
epiglottitis, 448 
diagnosis of, from Klebs-Loeffler 

bacillus, 478 
in infection of tonsils, 438 
in membranous laryngitis, 460 
Streptodiphtheria, 481 

of nose, 483 
Streptodiphtheritic angina in diphtheria, 

482 
Stricture of external auditory meatus, 663 
Stoerk's blennorrhea, 286, 468 
Stubbs' operation for adenoids, 343 
Stuttering, 537 
Stylomastoid foramen, 995 
Stylopharyngeus muscle, 995 
Subacute mastoiditis, 769 
Subdermal suture, Halsted's, 220 
Subglottic laryngitis, 456 

space, chondromata of, 546 
cysts of, 546 
importance of, 507 
neoplasms of, 546 

electrocautery for, 546 
Subhyoid pharyngotomy, 565 
Subjective laryngitis, chronic, 468 

noises, 1018 
" Submerged tonsils," 634 
of Pynchon, 408 ■ 
Submucous resection of nasal septum, 

82 7 100 
Subperiosteal mastoid abscess, 770 
Sudden death after operations for laryn- 
geal carcinoma, 574 
Sulcus tympanicus, 610 
Sunstroke, chronic bulbar paralysis from, 

366 
Suppuration of atrium of ear, 781 
of attic of ear, 781, 783 
of cervical glands, 398 
of labyrinth, 1008 
Suppurative diseases of ear, lymphatic 
glands and, 28 
otitis media, acute, 742 
rhinitis, 160 

sinuitis, treatment of, 191 
Supraglottic laryngitis, 456 
Supratonsillar fossa, 384, 391, 419 
"Swell bodies," 18, 24. See also Turbi- 
nated bones. 
in acute rhinitis, 131 



1074 



GENERAL INDEX 



"Swell bodies" in hypertrophic rhinitis, 

143 
Swivel knife, 151 

Ballenger's mucosa, 105 

in submucous resection of nasal 
septum, 91, 92, 96 
turbinotome, Ballenger's, 146 
Syncope, bronchial, 511 

laryngeal, 511 
Syphilis, acquired malformations of 
larynx and, 501 
acute catarrhal laryngitis and, 450, 
453 
otitis media and, 708 
infectious epiglottitis and, 448 
arteriosclerosis of labyrinth and, 1005 
deaf-mutism and, 1025 
destruction of uvula and, 362 
diagnosis of, from simple acute 

pharyngitis, 352 
edema of larynx and, 462 
of external ear, condyloma in, 321 
of fauces, 317 

hemorrhagic laryngitis and, 472 
hyperostosis of external auditory 

meatus and, 662 
of internal ear, 1007 

course of, 1008 
deafness in, 1008, 1009 
diagnosis of, 1008 

from hyperostosis of 
bony capsule of laby- 
rinth, 1008 
dizziness in, 1007 
. - nystagmus in, 1007 
ozena in, 1007 
pathology of, 1007 
prognosis of, 1008 
Rhine test in, 1007 
symptoms of, 1007 
tinnitus in, 1007 
treatment of, 1008 
Weber test in, 1007 
laryngeal paralysis and, 519, 521, 

522 
of larynx, 319 

diagnosis of, from chronic laryn- 
gitis, 473 
from tuberculosis of larynx, 
312 
pathology of, 319 
symptoms of, 319 
treatment of, 320 
malformations of pharynx and, 362 
neoplasms of larynx and, 545 
of nose, 33, 317 
pachydermia laryngis and, 500 
papilloma of larynx and, 546 
of pharynx, 317 

diagnosis of, from actinomycosis 
of pharynx, 328 
from tuberculosis of the 
pharynx, 308 
prolapse of ventricle of Morgagni 
and, 502 



Syphilis, sinuitis and, 176 

stenosis of larynx and, 501, 502 

throat in, 33 

of tonsils, 317 
Syphilitic coryza, 33 

otitis interna, 1007 
Syringe, Beck's paraffin, 299 



Tabes dorsalis, ear in, 32 

throat in, 32' 
Tachycardia in diphtheria, 481 

nasal, 268 
Teasing needle for Thiersch's grafting, 

855 
Teeth, adenoids and, 345 

caries of, sinuitis and, 177 
relation of, to maxillary sinus, 230 
singing voice and, 532 
Tegmen tympani, drainage through, in 
surgery for abscess of brain, 
976 
necrosis of, 838 
relations of, 606, 608 
Temporal bone, surgery of, 819 

cells, distribution of, 610 
Tenotomy of tensor tympani muscle, 677 
Teratoma of pharynx, 368 
treatment of, 369 
Tetanus, spasm of larynx in, 508 
"Theatre pain," 185 

Thiersch grafts, application of, after 
radical mastoid operation, 854, 

855, 856 
for deformity of nose, 293 
razor for, 854 
spatula for, 855 
Thimble gag, 597 
Thiosinamin in rhinoscleroma, 288 
Thornwaldt's disease, 331, 347 
Throat, bleeding in, 472 

general medicine and, 26 
in multiple sclerosis, 32 
in syphilis, 33 
in tabes dorsalis, 32 
Thrombophlebitis, infection through ton- 
sil and, 382 
Thrombosis, 809 

bacteriology of, 809 
of cavernous sinus, 817 

symptoms of, 818 
treatment of, 818 
of ear, embolic abscesses and, 810 
of jugular bulb, 816 

Whiting's test for, 816 
of lateral sinus, 789, 810 

acute primary mastoiditis 

and, 824 
bacteremia and, 814 
blood count in, 814 

cultures in, diagnostic 

value of, 813 
diagnosis of, early, 812 



GENERAL INDEX 



1075 



Thrombosis of lateral sinus, blood in eti- 
ology of, 810 
headache in, 812 
metastatic enteritis in, 
812 
meningitis in, 812 
pneumonia in, 812 
prognosis of, 816 
stages of, 812 
symptoms of, 812 
tenderness over mastoid 

emissary vein in, 812 
treatment of, surgical, 983- 
986 
pathology of, 810 
Thymic asthma, 509. See also Laryn- 
gismus stridulus. 
Thymus gland in diphtheria, 480 

enlarged, laryngismus stridulus 
and, 509 
Thyroid extract in hyperostosis of bony 
capsule of labyrinth, 740 
gland, enlarged, laryngeal paralysis 
and, 521 
Thyroidectomy, laryngeal paralysis and, 

521 
Thyrotomy, 502, 546, 558, 561, 564 
Timbre of voice, 528, 530 
Tinnitus in adhesive processes of middle 
ear, 727 
in arteriosclerosis of labyrinth, 1005 
aurium, 615, 1018 

in acute diffuse suppurative 

manifest labyrinthitis, 945 
alcohol and, 720, 727 
in chronic moist catarrhal otitis 

media, 719, 720 
prognosis of, 1020 
treatment of, 1020 
in concussion of labyrinth, 1011 
in deaf-mutism, 1030 
from disease of cochlea, 63 
in hyperemia of labyrinth, 1000 
in hyperostosis of bony capsule of 

labyrinth, 739 
in Meniere's disease, 1002 
physiological law of, 607 
in syphilis of internal ear, 1007 
syphilitic condyloma of external ear 
and, 321 
Tobacco, chronic laryngitis and, 465 
pharyngitis and, 353, 354 
hyperacuteness of hearing and, 1016 
in hyperemia of labyrinth, 1000 
laryngeal carcinoma and, 554 
neuroses of pharynx and, 364 
vestibular nystagmus and, 335 
Tone blindness, singing voice and, 533 
"islands," 615 
perception of, 618 
Tongue, base of, diseases of, 331 

singing voice and, 527 
Tongue-tie, 527, 532 
Tonsil, absorptive properties of, 385 
actinomycosis of, 326 



Tonsil, adhesions of, 387 
anatomy of, 383 
angioma of, 442 
bacteriolysis in, 386 
as barriers to microorganisms, 380, 

381 
blood supply of, 390 
calculus of, 403 
carcinoma of, 444 
crypts of, 384 
cystoma of, 443 
"decapitation" of, 392 
diseases of, 379 
ecraseur, Ballenger's, 421 
enucleation of, Beck-West method 

of, 426, 427 
epithelium of, 385 
Eustachian, 633 

tube and, 415 
extirpation of, by external route, 445, 

446 
faucial, acute catarrhal otitis media 
and, 708 
diffused hypertrophic laryngitis 

and, 467 
lymphoid tissue of, 383, 384 
fibro-enchondroma of, 443 
fibroma of, 442 
forceps, Ballenger's, 418 
function of, 392 
"germ centres" of, 384 
hemostat, Boetcher's, 422 

Pynchon's, 422 
horny material in, 409 
hyperkeratosis of, 408 
tonsillitis and, 410 
hyperplasia of, 408 
hypertrophy of, 408 

defective hearing from, 634 
treatment of, 408 
hypodermic syringe, Street's, 418 
infection of, rheumatic fever and, 
381, 382 
streptococcus in, 438 
thrombophlebitis and, 382 
through, endocarditis and, 382, 
391, 398 
pulmonary gangrene and, 
381,382 
inflammatory diseases of, 395 

general considerations of, 395 
internal secretion in, 392 
invasion of, by microorganisms, 379, 

380, 381 
knife, Ballenger's, 424 
laryngeal, in acute lacunar tonsil- 
litis, 398 
leptothrix in, 408 
lingual, 348 

hypertrophy of, 349, 350 
lymphoid tissue of, 348, 351 
removal of, 350 
lipoma of, 442 

local lesions of, acute lacunar ton- 
silitis and, 396 



1076 



GENERAL INDEX 



Tonsil, lymphadenoma of, in Hodgkin's 
disease, 444 
lymphatic infection through, 379, 

381, 382, 387, 388, 390 
lymphatics of, 387 
mycosis leptothricia of, 408 
neoplasms of, 442, 444 
operations on, 416 

acute articular rheumatism and, 

416 
Ballenger's, with scalpel, 423 
cocaine anesthesia in, 418, 420, 

429 
complete, 416 

Ballenger's, with right-angle 

knife and ecraseur, 417 

with capsule intact, 431 

with tonsillotome and 

punch forceps, 427 

complications of, 435 

extirpation by external route, 

445, 446 
by finger dissection, 441 
hemophilia and, 416 
hemostat for, Boetcher's, 422 

Pynchon's, 422 
indications for, 414 
infection following, 436, 437 
mouth-gag in, 418, 437 

reverse Trendelenburg, 440 
Pynchon's cautery dissection, 

429 
Robertson's, 428 
sequelae of, 437 
Sluder's guillotine, 431 
Street's hypodermic syringe for, 

418 
tonsillectomy, 423, 441 
tonsillotomy, 431, 436 
papilloma of, 442 

pharyngeal, in acute lacunar tonsil- 
litis, 398 
angina lacunaris of, 331 
lacunar inflammation of, acute, 
331, 332 
as portals of infection, 379 
punch forceps, Farlow's, 427 
Rhodes', 427 
Ruault's, 427 
removal of, 383, 392 

hemorrhage and, 392, 393 
sarcoma of, diagnosis of, from carci- 
noma, 445 
scarlet fever and, 381 
scissors, Robertson's, 428 
"submerged," 634 

of Pynchon, 408 
surgery of, 414 
syphilis of, 317 
syringe, Ballenger's, 441 
tuberculosis of larynx and, 309 
latent, 379 
primary, 379 
as vestigial organs, 380 
Tonsillar lymphatic vessels, 387, 388 



Tonsillar ring, 331, 338, 381 
Tonsillectomy, 423, 441 
anesthesia in, 417 
cervical cellulitis and, 392 
with scalpel, 423 
Tonsillitis, acute catarrhal laryngitis and, 
450 
cryptic, 396 
follicular, acute, 396 
hyperkeratosis of tonsils and, 410 
infective, 396 
lacunar, acute, 396 

acute articular rheumatism 

and, 398 
age and, 396 
bacteriology of, 396 
catching cold and, 396 
complications of, 396 
diagnosis of, 398 
from diphtheria, 398 
erythema multiforme and, 
399 
nodosa and, 399 
etiology of, 396 
laryngeal tonsils in, 398 
local lesion of tonsil and, 

396 
pathology of, 397 
pharyngeal tonsils in, 398 
seo-elsp of, 398 
speci^V fevers and, 397 
surgical trauma and, 396 
symptoms of, 397 
objective, 397 
subjective, 397 
treatment of, 397 
chronic, 402 

cholesterin in, 402 
etiology of, 402 
rheumatism and, 403 
symptoms of, 402 
treatment of, 403 
lingual, acute catarrhal, 349 
lacunar, 349 
phlegmonous, 349 
phlegmonous, 404. See also Peri- 
tonsillitis, 
ulcerative, 400 
Tonsillotome, 427 

Mathieu's, 417 
TonsiUotomy, 431, 436 
Torticollis in meningitis serosa, 790 
Toxemia, nystagmus and, 907 
Toxic angina in diphtheria, 482 
Trachea, diphtheria of, 484 

foreign bodies in, 577 
Tracheal diphtheria, 484, 578 
Tracheobronchoscope, Jackson's self-illu- 
minating, 591 
Tracheobronchoscopy, 579 
lower, 594 

indications for, 594 
position of patient in, 594 
upper, 589 

anesthesia for, 589 



GENERAL INDEX 



1077 



Tracheobronchoscopy, upper, introduc- 
tion of slide speculum in, 
591 
of tracheobronchoscope in, 
591 
position of head for, 590 
preparation of patient in, 589 
removal of foreign bodies in, 593 

of secretions in, 593 
topical applications in, 593 
Tracheoscopy, 581 

anesthesia for, 581 
Boyce's position for, 581, 582 
complications of, 584 
inspection in, 584 
introduction of tube in, 582 
pneumonia and, 584 
position of patient in, 581 
preparation of patient for, 581 
removal of foreign bodies in, 584 
Tracheotomy, 490 

in abscess of larynx, 464 
accidents in, 491 

in acute phlegmonous laryngitis, 559 
catarrhal laryngitis, 454, 455 
infectious epiglottitis, 449 
laryngitis in children, 458 
after-effects of, 491 
after-treatment of, 492 
complications of, 491 
in diphtheria, 486, 490 
in discrete hypertrophic laryngitis, 

469 
in edema of larynx, 463 
high, 490 
incision in, 490 

indications for, 449, 454, 455, 458, 

459, 460, 463, 464, 469, 490, 505, 

506, 520, 523, 524, 546, 548, 579, 

in laryngeal paralysis, 520, 522, 523, 

524 
low, 490, 594 

after-treatment in, 595 
introduction of tracheobroncho- 
scope in, 594 
in membranous laryngitis, 460 
in stenosis of larynx, 504, 505, 506 
tube, 490 

introduction of, 491 
Trachoma of vocal cords, 469 
Transillumination, 171, 172, 174 
of maxillary sinus, 279 
in sinuitis, 171, 181, 182 
Traumatic circumscribed labyrinthitis, 

906 
Trautmann tongue flap method in radical 

mastoid operation, 846 
Trendelenburg position, reverse, for oper- 
ations on tonsils, 440 
Trephine, Bishop's, 229 

circular, 978 
Trocar, Krause's, 225 
Trousseau's dilator, 594 
Trypsin treatment for malignant neo- 
plasms, 376/ 



Tubal catarrh, 684 

adenoids and, 684, 685 
epipharyngitis and, 684 
etiology of, 684 
prognosis of, 685 
symptoms of, 685 
treatment of, 685, 686, 687 
disease, acute catarrhal otitis media 
and, 708 
Tuberculosis, acquired malformations of 
larynx and, 501 
acute catarrhal laryngitis and, 450 
otitis media and, 708 
infectious epiglottitis and, 
448 
deaf -mutism and, 1030 
edema of larynx and, 462, 463 
of fauces, 307 

hemorrhagic laryngitis and, 472 
laryngeal paralysis and, 515 
of larynx, 308 

aphonia in, 311 

"ashen-gray" color in, 310, 311 
cocaine in, 313 
Cooper-Hewitt light for, 313 
cough in, codeine for, 312 
curettage for, 314 
diagnosis of, 312 

from carcinoma of larynx, 

312 
from chronic laryngitis, 473 
from lupus of larynx, 312 
from syphilis of larynx, 312 
dysphagia in, 308 
dyspnea in, 308 
etiology of, 309 
menthol in, 313 
orthoform in, 313 
pathology of, 310 
prognosis of, 312 
radiotherapy for, 313 
radium in, 315 
Rontgen rays in, 313 
symptoms of, 311 
tonsils and, 310 
treatment of, 312 
ultraviolet rays in, 313 
of mastoid process, 314 
of middle ear, 314 

destruction of bony tissue 
of labyrinth in, 316 
of mastoid process in, 
316 
diagnosis of, 315 
Koch's tuberculin in, 315 
prognosis of, 316 
symptoms of, 315 
treatment of, 316 
of nose, 307 

perforation of septum and, 307 
radiotherapy for, 307 
pachydermia laryngis and, 500 
papilloma of larynx and, 546 
of pharynx, 307 

diagnosis of, 30S 



1078 



GENERAL INDEX 



Tuberculosis of pharynx, diagnosis of, 
from syphilis, 308 
prognosis of, 308 
symptoms of, 308 
treatment of, 308 
prolapse of ventricle of Morgagni 

and, 502 
pulmonary, stammering and, 540 
sinuitis and, 176 
of tonsils, 379 
Tuberculous cervical glands, 316 

disease of pharynx, diagnosis of, 
from actinomycosis of pharynx, 
327 
laryngitis, 308 

in pregnant women, 314 
membrana tympani, 315 
otitis, 316 

stenosis of larynx, 504 
Tuning forks, Bezold-Edelmann, 617 
Turbinal region of nose, middle, obstruc- 
tion of, 119 
Turbinated bones, hypertrophy of, 142 
middle, enlargement of, asthe- 
nopia due to, 35 
hemorrhage from, 153 
obstruction of nose due to, 

129 
removal of, with Ballenger's 
turbinotome, 150 
with Holmes' scissors, 

150 
with scissors and snare, 

150 
with swivel knife, 151 
of nose, 17, 18 

in obstructive deviations of 
nasal septum, 63 
region, middle, sinuitis due to pres- 
sure in, 188 
Turbinectomy with Ballenger's knife, 

239 
Turbinotome, Ballenger's, 150 

swivel, 146 
Turbinotomy, meningitis following, 242 

middle, meningitis after, 153 
Turning reactions in diffuse latent sup- 
purative labyrinthitis, 950 
_ test of vestibular apparatus, 877 
Twisted or crooked nose, Ballenger's 

operations for, 291, 292, 293 
Tympanic cavity, 606 

auscultation of, 696, 697, 702 
contents of, 606 
curettage of, dangers of, 836 
function of, 611 

infection of, brain abscess and, 
608 
meningitis and, 608 
inflammatory diseases of, 703 
inflation of, 692. 

in acute catarrhal otitis 

media, 714, 715 
in adhesive processes of 
middle ear, 728, 729 



Tympanic cavity, inflation of, diagnostic 
value of, 694, 698, 701 
manometer in, 697 
methods of, 694 
American, 700 
by catheterization, 695 
by external mechanical 

massage, 701 
Politzer's, 699 

modified, 700 
Valsalva's, 694 
principles of, 692, 693 
relations of, 606 

to facial nerve, 835 
removal of necrosed bone from, 
in radical mastoid operation, 
838 
walls of, 608 
murmur in acute suppurative otitis 
media, 749 
Tympanum, 606 
Typhoid, epistaxis and, 284 

fever, hemorrhagic laryngitis and, 
472 
hyperemia of labvrinth and, 

1000 
laryngeal paralysis and, 515 



Ulcerative tonsillitis, 400 
Ultraviolet rays, 313 

in lupus of nose, 306 
in tuberculosis of larynx, 313 
Uncinate cells, obstruction of nose due to, 
119 
process, 118, 174, 199 
Upper tracheobronchoscopy, 589 
Urine in diphtheria, 485 
Uterine disease, laryngismus stridulus 

and, 509 
Utricle, cristae of, 870 
Uvula, amputation of, 357, 358 

Casselberry's operation for, 356 
edema of, 355 
elastic, 357 
elongation of, 356 

reflex cough in, 356 
singing voice and, 531 
symptoms of, 356 
treatment of, 357 
syphilitic destruction of, 362 
voice and, 525, 526 , J 



Vaccine therapy for disease of accessory 
sinuses of nose, 196 
for sinuitis, 196 

for suppurative otitis media, 776 
Vagus paralysis in diphtheria, 486 
Vail's antrum saw, 226 

operation upon maxillary sinus, 226 



GENERAL INDEX 



1079 



Valsalva's method of inflation of tym- 
panic cavity, 694 
Valvular lesions of heart, edema of 

larynx and, 462 
Variola, hemorrhagic laryngitis and, 472 
Varix, lingual, 350 

electrocautery in, 351 
glossodynia and, 351 
pathology of, 351 
symptoms of, 351 
treatment of, 351 
Vasomotor neuroses, nasal, 254 

system, unstableness of, chronic 
laryngitis and, 466 
Vegetations, adenoid, 333 
Vein, jugular, internal, resection of, 987, 

988 
Velum palati, paralysis of, in diphtheria, 

486 
Ventricles of larynx, prolapse of, diagnosis 
of, from chronic laryngitis, 473 
of Morgagni, prolapse of, 502 
syphilis and, 502 
tuberculosis and, 502 
Vertigo in acute diffuse serous labyrinth- 
itis, 936 
circumscribed labyrinthitis, 904, 906, 

932 
in extradural abscess, 793 
intractable and unbearable, 975 
laryngeal, 511 
in Meniere's disease, 1002 
in neurasthenics, 907 
in obstructive deviations of nasal 

septum, 63 
in sinuitis, 163, 186 
Vestibular apparatus, function of, 613 

qualitative estimation of, 

896 
quantitative estimation of, 

896 
tests of, 629 
tests of, caloric, 881 

with cold water, 883 
significance of, 887 
with warm water, 886 
clinical problems in, 893 
fistula, 888 

hindrances to, 890 
significance of, 890 
functional, 877 
galvanic, 891 

significance of, 893 
turning, 877 

significance of, 898 
nystagmus, 870 

reaction in acute diffuse suppurative 
manifest labyrinthitis, 942 
Vibrator, mechanical, 45 
"Vicious circle" of nose, 199 
Victor massage apparatus, 716 
Vincent's angina, 400 
Vocal bands, removal of, 524 

cords, "cadaveric" position of, 519, 
521 



Vocal cords, color of normal, 466 

paralysis of. See Paralysis, 

laryngeal, 
spasm of tensor muscles of, 

509 
trachoma of, 469 
Voice in acute catarrhal laryngitis, 
453 
in chorditis nodosa, 470 
in deaf -mutism, 1029 
in diffused hypertrophic laryngitis, 

466 
in edema of larynx, 463 
excessive use of, in hemorrhagic 

laryngitis, 472 
falsetto, 540 

in fibromata of pharynx, 370 
foreign bodies in respiratory passages 

and, 577 
influence of puberty on, 525 
in laryngeal diphtheria, 483 

paralysis, 516, 522 
in membranous laryngitis, 460 
operations for laryngeal carcinoma 

and, 575 
pillars of fauces and, 530 
production, 525 
range of, 525 
resonators of, 529, 530 
singing, adenoids and, 526, 531 
chronic pharyngitis and, 531 
cleft palate and, 532 
defects in, causes of, 525 

treatment of, 533 
elongation of uvula and, 531 
improper methods of respiration 

and, 532 
laryngitis and, 534 
larynx and, 527 
nasal chambers and, 532 

diseases and, 526, 534 
papillomata and, 527 
pharynx and, 531 
sinuitis and, 534 
teeth and, 532 
tone blindness and, 533 
tongue and, 527, 531 
tongue-tie and, 527, 532 
in syphilitic stenosis of larynx, 

503 
test for hearing, 619 
throatiness of, 530 
timbre of, 528, 530 
uvula and, 525, 526 
Voltolini's method for removal of foreign 

bodies in ear, 641 
Vomer, removal of, in submucous resec- 
tion of nasal septum, 94, 95 
Vomiting in acute diffuse serous laby- 
rinthitis, 936 

in Meniere's disease, 1002 
von Langenbeck's operation for 

fibroma of nose, 277 
von Troltsch's method of gargling, 
6S6 



1080 



GENERAL INDEX 



W 



Waldeyer's ring, 329, 336, 379 
Walsham's operation for collapse of alae 

nasi, 302 
"Warty diathesis," 545 
Watson's operation for deviation of nasal 

septum, 73, 74 
Weaver's intratympanic masseur, 690 
Weber test in acute catarrhal otitis media, 
711 
suppurative otitis media, 
745 
on bone conduction, 616 
for hearing, 616, 621, 622 
for impacted cerumen, 643 
in syphilis of internal ear, 1007 
in unilateral deafness, 622 
Weber-Liel catheter, 758, 819 
Wells' trocar cannula, 229 
Westphal's symptoms in leptomeningitis, 

795 
Wet cupping, 123 
Whistle, Galton-Edelmann, 321, 626 



Whiting's encephaloscope, 981 
incision, 825 

test for thrombosis of jugular bulb. 
816 
Wilde's incision, 824 

for acute periostitis of mastoid 
process, 770 
Wooden tongue, 325 
Word-deafness, 1020 



X-rays. See Rontgen rays. 



Yankatjer's intranasal suture for per- 
foration of nasal septum, 107, 108 

Yellow fever, hemorrhagic laryngitis and, 
472 



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